Get with the Guidelines® - Stroke PMT®

Abstraction Guidelines Updated August 2022

Print Coding Instructions

Legend

Yellow Highlighted Text = Updated since last version of document

^ = The Joint Commission Data Element

^^ = Get with the Guidelines® (GWTG)® Stroke data element

The Joint Commission (TJC) PSC/Core Measure definition for the element listed (definition from the TJC manual)

The Joint Commission (TJC) Comprehensive Stroke (CSTK) definition for the element listed

The Joint Commission (TJC) Acute Stroke Ready (ASR) definition for the element listed

Coverdell field definition

Green Highlighted Text = TJC updates from the Specifications Manual for National Hospital Inpatient Quality Measures since last version of document

Suggested Sources for Abstraction

Table of Contents


Entry Criteria

Patients with a final/discharge diagnosis of stroke or transient ischemic attack can be included into the GWTG-Stroke® Registry. This includes cases with a

Following is a list of the ICD-10-CM codes commonly used to describe these diagnoses.


ICD-10-CM (for discharges on or after October 1, 2015)
Code Short Description
I60.00 - I60.9 Non-traumatic subarachnoid hemorrhage
I61.0 - I61.9 Non-traumatic intracerebral hemorrhage
I63.00 - I63.9 Cerebral Infarction (occlusion and stenosis of cerebral and precerebral arteries, resulting in cerebral infarction)
G45.0 - G45.2 TIA and related syndromes*
G45.8 - G45.9 TIA and related syndromes*
O99.411 - O99.43 Diseases of the circulatory system complicating pregnancy, childbirth and puerperium

Additional Entry Criteria: Unique to GWTG® - Stroke
Code Short Description
G97.31 - G97.32 Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating a procedure
G97.51 - G97.52 Post-procedural hemorrhage and hematoma of a nervous system organ or structure following a procedure
I97.810 - I97.821 Intraoperative and postoperative cerebrovascular infarction

Note for Stroke Core Measure and/or TJC users: Verify that the patients being entered GWTG comply with patient population requirements (as outlined by TJC stroke core measure set) by checking tables 8.1 and 8.2 in the most current specifications manual of The Joint Commission.

TJC Measure Specifications Manuals

TJC Table Number 8.1: Ischemic Stroke, Version 2022B1

TJC Table Number 8.2: Hemorrhagic Stroke, Version 2022B1


Note for Coverdell users: Based upon the recommendations of PCNSAR clinical consultants, PCNAST does not require hospitals to include patients who are observation patients in the registry.

Included:

Optional:

Exclude:

Summary of Changes

ADDITIONAL ENTRY CRITERIA & CASE ASCERTAINMENT INFORMATION:
Select the links below to access information about the specific program(s).

Arkansas Additional Data Elements
Los Angeles County EMS Additional Data Elements
Massachusetts Primary Stroke Service Licensure Registry (PSS)
Mission: Lifeline Stroke in North Dakota
New Jersey Acute Stroke Registry (NJASR)
New York State Additional Data Elements
Ohio Special Initiatives Tab - Coverdell Stroke Program
Paul Coverdell National Acute Stroke Registry (PCNASR)
The Joint Commission Primary Stroke Certification


General notation:


Abstraction Guidelines:

Summary of Changes


Suggested Sources:

Pre-hospital Data may include: EMS Patient Care records (also known as transport sheets, trip sheets, or trip records).

Admission Data may include:

Hospitalization Data may include:

Discharge Data may include:


Patient Identifier (Patient ID)
Required Field

Definition: Unique number assigned to a patient by the site (your hospital) for an admission. Only an identifier that contains no personal health information (PHI) is to be entered.

Data Collection Question: What is the patient identifier associated with the patient you would like to enter in the PMT?

Format:

Allowable values:

Notes for Abstraction:

Sources for Data:

Admin Tab

REQUIRED: Final clinical diagnosis related to stroke

This field is used to define patient populations in the Get With The Guidelines® Stroke Measures and is the stroke or TIA diagnosis documented by a physician following and evaluation of the patient. The Final clinical diagnosis related to stroke (stroke or TIA diagnosis) may be a principal or secondary diagnosis assigned at discharge. The options for this element are:

Refer to Entry Criteria for a list of the diagnosis codes used to describe these diagnoses.

Notes for Abstraction:

Example: Patient 060a was admitted with pneumonia. On hospital day 2 patient developed right sided weakness and was diagnosed with an ischemic stroke. Final clinical diagnosis related to stroke = "Ischemic Stroke."

Admission Data, Hospitalization Data

Summary of Changes

OPTIONAL: If No Stroke Related Diagnosis

If “Final clinical diagnosis related to stroke” is “No Stroke Related Diagnosis”, select the final non-stroke related diagnosis. This is the final diagnosis defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care." and not the suspected diagnosis at the time of admission. Select the patient's diagnosis based on the clinical information found in the medical record. If uncertain, consult ICD-9-CM diagnosis code.

Notes for abstraction:

Summary of Changes

REQUIRED: Was an etiology documented in the patient medical records as the most likely cause of ischemic stroke?

Yes: There is clear documentation by a physician, nurse practitioner or physician’s assistant in the patient medical record indicating that apotential underlying cause(s) of ischemic stroke was identified. This option should be selected when there is evidence in the medical record that the stroke etiology was investigated, even if no cause was identified despite the investigation or if multiple potential causes were identified.

Remember that there can never be absolute certainty about etiology, since it is always an assumption about the likelihood of an association between the cause (ischemic stroke risk factor) and effect (ischemic stroke).

No: The documentation by a physician, nurse practitioner or physician’s assistant in the patient medical record does not address the potential cause of the ischemic stroke. Select No if sufficient diagnostic tests were not performed to identify a potential cause. If multiple etiologies are listed on admission but no synthesis of the results of the workup is provided, then no presumptive etiology is available. You would check No in this case.

Diagnostic statements such as CVA, stroke, cerebral embolism, MCA stroke do not describe a cause of potential cause. If diagnostic evaluation to investigate a cause(s) was not performed then select No.

Ischemic Stroke Etiology: If there is one cause identified as the most likely etiology, select that one choice. You should only select a specific etiology (e.g., Cardioembolic) if the medical record indicates that the treating provider believed this to be a possible mechanism. If the etiology is uncertain between two or more possible causes, select Cryptogenic Stroke and Multiple potential etiologies identified. Do not include etiologies that were identified initially as possibilities which were not later confirmed. If you are uncertain as to which etiology to select, check with your stroke physician champion.

1: Large-artery atherosclerosis: Significant stenosis or occlusion (>50%) due to atherosclerosis of any of the following major artery segments was identified: common or internal carotid artery (ICA); proximal middle (MCA), anterior or posterior cerebral artery (ACA or PCA); vertebral or basilar artery. This option also includes atherosclerosis of the aortic arch and its great vessel origins: the brachiocephalic and subclavian arteries.

2: Cardioembolism: A cardiac condition was identified as a high risk source of cerebral embolism. Possible heart conditions include atrial fibrillation/flutter, mitral valve stenosis, prosthetic or bioprosthetic heart valve, left ventricular assist device, acute or recent myocardial infarction with mural thrombus, endocarditis and cardiac tumors.

3: Small-vessel disease: Disease of small intracerebral arterial vessels was identified as cause of ischemic stroke. Imaging reveals an acute small vessel territory infarct <1.5 cm in the appropriate location (e.g. subcortical or brain stem lacunar infarction) or a classic clinical lacunar syndrome is present and imaging excludes non-lacunar etiology.

4: Stroke of other determined etiology: Select this option when an uncommon causes of ischemic stroke has been identified, including but not limited to, arterial dissection, vasculitis, hypercoagulable disorders, sickle cell anemia, migraine-associated, mitochondrial disorders (e.g., MELAS), or genetic causes of stroke. Also select Dissection or Hypercoagulability as the cause when appropriate. Select Other if another cause of the stroke has been identified (e.g., vasculopathy).

5: Cryptogenic stroke: A potential cause of stroke was not identified following thorough diagnostic evaluation: This includes a diagnosis of undetermined cause following diagnostic evaluation. Select this option only if testing to determine stroke etiology has been performed and does not confirm a likely cause or when multiple potential etiologies are identified. For most strokes, this includes cardiac ultrasound, extracranial arterial vessel imaging (carotid artery ultrasound, CTA or MRA). Patients with an undetermined cause of stroke (cryptogenic stroke) often have one or more risk factors of uncertain significance such as patent foramen ovale (PFO), heart failure with preserved ejection fraction, mitral annulus calcification, atrial or ventricular arrhythmias other than atrial fibrillation or flutter. The role of these risk factors in the cause of stroke is uncertain. Also select one of the below options to report additional information regarding the cause or potential causes:

Examples:

Summary of Changes

REQUIRED: When is the earliest documentation of comfort measures only?

Indicate if there is any evidence that the patient's care was restricted to "Comfort Measures Only".

Physician/advanced practice nurse/physician assistant (physician/APN/PA) documentation of comfort measures only. Commonly referred to as "comfort care" in the medical community and "comfort care" by the general public. Comfort care includes attention to the psychological and spiritual needs of the patient and support for the dying patient and the patient's family. Comfort Measures Only are not equivalent to the following: Do Not Resuscitate (DNR), living will, no code, no heroic measure, or a physician order to withhold emergency resuscitative measures such as Do Not Resuscitate.

Notes for Abstraction:

Suggested Data Sources:

PHYSICIAN/APN/PA DOCUMENTATION ONLY IN THE FOLLOWING ONLY ACCEPTABLE SOURCES:

Discharge Summary

DNR/MOLST/POLST forms

Emergency department record

Physician orders

Progress notes

Excluded Data Sources: Restraint order sheet

Inclusion Guidelines for Abstraction:

Brain dead

Brain death

Comfort care

Comfort measures

Comfort measures only (CMO)

Comfort only

DNR-CC

End of life care

Hospice

Hospice care

Organ harvest

Terminal care

Exclusion Guidelines for Abstraction:  None

REQUIRED: Arrival Date/Time (Date & time of arrival to this Hospital)

Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

The earliest documented month, day, and year, and time the patient arrived at the hospital.

Time must be recorded in military time format.

With the exception of Midnight and Noon:

Examples:

Note: 00:00 = midnight. If the time is documented as 00:00 11-24- 20XX , review supporting documentation to determine if the Arrival Date should remain 11-24- 20XX or if it should be converted to 11-25- 20XX .

When converting Midnight or 24:00 to 00:00 do not forget to change the Arrival Date.

Example: Midnight or 24:00 on 11-24- 20XX = 00:00 on 11-25- 20XX

Notes for Abstraction (Date/Time):

Suggested Data Sources:

ONLY ACCEPTABLE SOURCES:

Inclusion Guidelines for Abstraction: None

Exclusion Guidelines for Abstraction: Addressographs/stamps

Summary of Changes

REQUIRED: Admit Date

Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

The month, day, and year of admission to acute inpatient care.

Notes for Abstraction:

Suggested Data Sources:

Note: The physician order is the priority data source for this data element. If there is not a physician order in the medical record, use the other only allowable sources to determine the Admission Date.

ONLY ALLOWABLE SOURCES

  1. Physician orders
  2. Face Sheet
  3. UB-04

Excluded Data Sources
UB-04 "From" and "Through" dates

Inclusion Guidelines for Abstraction: None

Exclusion Guidelines for Abstraction:

Summary of Changes

OPTIONAL: Not Admitted?

Was patient evaluated in the ED for acute Stroke or TIA and never admitted as an inpatient to your hospital?

Note: Patients with a response option of “Yes, not admitted” will only be included in the following Achievement and Quality measures: alteplase measures, door to needle measures, dysphagia screen, CT measures, and NIHSS reported.

Reason Not Admitted
Required field only when patient is not admitted to your hospital

Definition: If patient was not admitted, indicate the primary reason why the patient was not admitted to your hospital.

Data Collection Question: Why was the patient not admitted to your hospital for this episode of care?

Format: Dropdown menu. Single -select.

Allowable values:

Notes for Abstraction:

Note: For patients with an ED discharge disposition of transferred from your ED to another acute care hospital, discharged directly from ED to home or other location that is not an acute care hospital, left from ED AMA, died in ED, or other, all post-admission fields in the following sections will be disabled:

These fields will remain open for patients that are discharged from observation status without an inpatient admission, however not all of these fields will be required for this subset of patients.

Sources for Data:

Select reason(s) for why patient transferred:

Appears for all users - only complete this field if you are the referring hospital and transferring the patient to another hospital.

Note: Required in patients who have "Not Admitted = Yes" and "Reason not admitted" = "Transferred from your ED to another acute care hospital"

Definition: The reason associated with the acute stroke patient transferred from the referring hospital emergency department (ED) to a different hospital (e.g. Primary Stroke Center, Comprehensive Stroke Center). Intent of the element is to determine the transfer rates and reason for transfer and how it may affect patient outcomes.

Data Collection Question: What was the reason for transferring the patient from your hospital to a different hospital? Check all applicable fields.

Format: Multi-select field

Allowable Values:
  • Evaluation for IV tPA up to 4.5 hours
  • Post Management of IV tPA (e.g. drip and ship)
  • Evaluation for endovascular thrombectomy
  • Advanced stroke care (e.g., Neurocritical care, surgical or other time critical therapy)
  • Other non-stroke advanced care
  • Patient/family request
  • Not documented


  • Notes for Abstraction:



    Collected for: GWTG® measures

    Definition: The date associated with the time that the patient was transferred from the referring hospital emergency department (ED). This is the time the patient left the ED.

    Data Collection Question:
    What is the date and time associated with patient discharged from the referring hospital ED to the transferring hospital?

    Format:

    Length: 15 MM-DD-YYYY :HH-MM (with or without color & includes dashes) or Unknown

    Type: Date and Time

    Occurs: 1

    Allowable Values:

    Date

    MM = Month (01-12)

    DD = Day (0-31)

    YYYY = Year (2012-Current Year)

    UTD = Unknown

    Time

    HH = Hour (00-23)

    MM = Minutes (00-59)

    UTD = Unknown

  • Time must be recorded in military time format. Except for Midnight and Noon
  • If the time is in the a.m., conversion is not required
  • If the time is in the p.m., add 12 to the clock time hour
  • Examples:

    Midnight - 00:00

    Noon = 12:00

    5:31 am = 05:31

    5:31 pm = 17:31

    11:59 am = 11:59

    11:59 pm = 23:59

    Note: 00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the First Radiographic Image Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.

    When converting Midnight or 24:00 to 00:00, do not forget to change the First Radiographic Image Date.

    Example:

    Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx

    Notes for Abstraction:

    Summary of Changes

    REQUIRED: Discharge Date and Time (Date and Time of discharge from hospital)

    Definition: Record the month, day, andyear the patient was discharged from acute care, left against medical advice, or expired during this stay.

    Notes for Abstraction:

    Sources of Data:

    Summary of Changes

    CONDITIONALLY REQUIRED: Documented reason for delay in transfer to referral facility?

    Note: Element enabled and required if patient is "yes, not admitted" AND "reason for not admitted = transfer to another acute care hospital" AND Reason for transfer = Evaluation for IV alteplase up to 4.5 hours OR Post Management of IV alteplase (e.g. Drip and Ship) OR Evaluation for Endovascular Thrombectomy AND discharge date time - arrival date/time is >90 minutes.

    Definition: A reason for delay of transfer from your facility to the referral facility is documented in the medical record.

    Allowable Values:

    Notes for Abstraction:

    Summary of Changes

    Specific reason for delay documented in transfer patient (check all that apply):

    Definition: Indicate the reason(s) documented for delay in transfer from your facility to the referral facility.

    Allowable Values:

    *Does not exclude patient from measure population

    Notes for Abstraction:

    Summary of Changes

    REQUIRED: For patients discharged on or after 04/01/2011: What was the patient’s discharge disposition on the day of discharge?

    Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

    Data Element Name: Discharge Disposition

    Collected For: ACHF, ASR-IP-3, CSTK-02, CSTK-10, HBIPS-5, PC-04, PC-05, STK-10, STK-2, STK-3, STK-6, STK-8

    Definition: The final place or setting to which the patient was discharged on the day of discharge.

    Data Collection Question: What was the patient's discharge disposition on the day of discharge?

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:
    1 Home
    2 Hospice - Home
    3 Hospice – Health Care Facility
    4 Acute Care Facility
    5 Other Health Care Facility
    6 Expired
    7 Left Against Medical Advice/AMA
    8 Not Documented or Unable to Determine (UTD)

    Notes for Abstraction:

    Suggested Data Sources:
    • Discharge instruction sheet
    • Discharge planning notes
    • Discharge summary
    • Nursing discharge notes
    • Physician orders
    • Progress notes
    • Social service notes
    • Transfer record
    • Any DMAT documentation record

    Excluded Data Sources:
    • Any documentation prior to the last two days of hospitalization
    • Coding documents
    • UB-04

    Inclusion Guidelines for Abstraction:
    Home (Value 1):

    • Assisted Living Facilities (ALFs) – Includes ALFs and assisted living care at nursing home, intermediate care, and skilled nursing facilities
    • Court/Law Enforcement – includes detention fa
    cilities, jails, and prison
    • Home – includes board and care, foster or residential care, group or personal care homes, retirement communities and homeless shelters
    • Home with Home Health Service
    • Outpatient Services including outpatient procedures at another hospital, Outpatient Chemical Dependency Programs and Partial Hospitalization

    Hospice – Home (Value 2):
    • Hospice in the home (or other “Home” setting as above in Value 1)

    Hospice - Health Care Facility (Value 3):
    • Hospice - General Inpatient and Respite
    • Hospice - Residential and Skilled Facilities
    • Hospice - Other Health Care Facilities


    Acute Care Facility (Value 4):
    • Acute Short Term General and Critical Access Hospitals
    • Cancer and Children’s Hospitals
    • Department of Defense and Veteran’s Administration Hospitals


    Other Health Care Facility (Value 5):
    • Extended or Immediate Care Facility (ECF/ICF)
    • Long Term Acute Care Hospital (LTACH)
    • Nursing Home or Facility including Veteran’s Administration Nursing Facility
    • Psychiatric Hospital or Psychiatric Unit of a Hospital
    • Rehabilitation Facility including Inpatient Rehabilitation Facility/Hospital or Rehabilitation Unit of a Hospital
    • Skilled Nursing Facility (SNF), Sub-Acute Care or Swing Bed
    • Transitional Care Unit (TCU)
    Veterans Home

    Exclusion Guidelines for Abstraction:
    None

    Summary of Changes

    REQUIRED if discharged to Other Healthcare Facility: If Other Health Care Facility

    If Other Health Care Facility is selected for Discharge Disposition, select the specific facility to which the patient was discharged.

    Summary of Changes


    Clinical codes

  • ICD-9-CM Principal Diagnosis Code
  • ICD-10-CM Principal Diagnosis Code
  • ICD-9-CM Other Diagnosis Codes
  • ICD-10-CM Other Diagnosis Codes
  • ICD-9-CM Principal Procedure Code
  • ICD-10-PCS Principal Procedure Code
  • No ICD-10-PCS Procedure Code Documented
  • ICD-9-CM Principal Procedure Date
  • ICD-10-PCS Principal Procedure Date
  • ICD-9-CM Principal Procedure Time
  • ICD-10-PCS Principal Procedure Time
  • ICD-9-CM Other Procedure Codes
  • ICD-10-PCS Other Procedure Codes
  • ICD-9-CM Other Procedure Dates
  • ICD-10-PCS Other Procedure Dates
  • ICD-9-CM Other Procedure Times
  • ICD-10-PCS Other Procedure Times
  • What was the ICD-9-CM diagnosis code selected as the admitting diagnosis for this patient?
  • What was the ICD-10-CM diagnosis code selected as the admitting diagnosis for this patient?
  • REQUIRED FOR TJC, COVERDELL & COMPREHENSIVE (for discharges on or before 9/30/2015): ICD-9-CM Principal Diagnosis Code

    Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

    The ICD-9-CM diagnosis code that is primarily responsible for the admission of the patient to the hospital for care during this hospitalization.

    Allowable Values:
    Any valid diagnosis code as per the ICD-9-CM master code table (ICD-9-CM Full and Abbreviated Code Titles):
    http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html

    Notes for Abstraction:

    The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."

    Suggested Data Sources:

    Inclusion Guidelines for Abstraction: None

    Exclusion Guidelines for Abstraction: None

    Summary of Changes

    REQUIRED FOR TJC, COVERDELL & COMPREHENSIVE (for discharges on or after 10/1/2015): ICD-10-CM Principal Diagnosis Code

    Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

    The ICD-10-CM diagnosis code that is primarily responsible for the admission of the patient to the hospital for care during this hospitalization.

    Allowable Values:
    Any valid diagnosis code as per the ICD-10-CM master code table (Code Descriptions in Tabular Order):
    https://www.cms.gov/Medicare/Coding/ICD10/index.html

    Notes for Abstraction:
    None

    Suggested Data Sources:

    Inclusion Guidelines for Abstraction: None

    Exclusion Guidelines for Abstraction: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE ONLY (for discharges on or before 9/30/2015): ICD-9-CM Other Diagnosis Codes

    The other or secondary ICD-9-CM codes associated with the diagnosis for this hospitalization.

    Allowable Values:
    Any valid diagnosis code as per the ICD-9-CM master code table (ICD-9-CM Full and Abbreviated Code Titles):
    http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html

    Notes for Abstraction:
    None

    Suggested Data Sources:

    Inclusion Guidelines for Abstraction: None

    Exclusion Guidelines for Abstraction: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE ONLY (for discharges on or after 10/1/2015): ICD-10-CM Other Diagnosis Codes

    The other or secondary ICD-10-CM codes associated with the diagnosis for this hospitalization.

    Allowable Values:
    Any valid diagnosis code as per the ICD-10-CM master code table (Code Descriptions in Tabular Order):
    https://www.cms.gov/Medicare/Coding/ICD10/index.html

    Notes for Abstraction:
    None

    Suggested Data Sources:

    Inclusion Guidelines for Abstraction: None

    Exclusion Guidelines for Abstraction: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE ONLY (for admissions on or before 9/30/2015): ICD-9-CM Principal Procedure Code

    The principal procedure is the procedure performed for definitive treatment rather than diagnostic or exploratory purposes, or which is necessary to take care of a complication.

    Allowable Values:
    Any valid procedure code as per the ICD-9-CM master code table (ICD-9-CM Full and Abbreviated Code Titles):
    http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html

    Notes for Abstraction:
    None

    Suggested Data Sources:

    Inclusion Guidelines for Abstraction: None

    Exclusion Guidelines for Abstraction: None

    Summary of Changes

    REQUIRED FOR TJC & COMPREHENSIVE: ICD-10-PCS Principal Procedure Code

    The principal procedure is the procedure performed for definitive treatment rather than diagnostic or exploratory purposes, or which is necessary to take care of a complication.

    Allowable Values:
    Any valid procedure code as per the ICD-10-PCS master code table (PCS Long and Abbreviated Titles):
    https://www.cms.gov/Medicare/Coding/ICD10/index.html

    Notes for Abstraction:
    None

    Suggested Data Sources:

    Inclusion Guidelines for Abstraction:None

    Exclusion Guidelines for Abstraction: None

    Summary of Changes

    No ICD-10-PCS Procedure Code Documented

    Check this box if there is no ICD-10-PCS Code documented in the medical record.

    Notes for Abstraction:

    Suggested Data Sources:

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE ONLY (for discharges on or before 9/30/2015): ICD-9-CM Principal Procedure Date

    The month, day, and year when the principal procedure was performed.

    Notes for Abstraction:

    Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commission's Data Warehouse. Use of "UTD" for ICD-9-CM Principal Procedure Date allows the case to be accepted into the warehouse.

    Suggested Data Sources:

    Inclusion Guidelines for Abstraction: None

    Exclusion Guidelines for Abstraction: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE ONLY (for discharges on or after 10/1/2015): ICD-10-PCS Principal Procedure Date

    The month, day, and year when the principal procedure was performed.

    Notes for Abstraction:

    Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commission's Data Warehouse. Use of "UTD" for ICD-10-PCS Principal Procedure Date allows the case to be accepted into the warehouse.

    Suggested Data Sources:

    Inclusion Guidelines for Abstraction: None

    Exclusion Guidelines for Abstraction: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE (for discharges on or before 9/30/2015): ICD-9-CM Principal Procedure Time

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: ICD-9-CM Principal Procedure Time

    Collected For: CSTK-01, CSTK-03

    Definition: The time (military time) when the principal procedure was performed

    Suggested Data Collection Question: What was the time that the principal procedure was performed?

    Format

    Length:
    5 - HH-MM (with or without colon) or UTD
    Type: Time
    Occurs: 1

    Allowable Values:

    HH = Hour (00-23)
    MM = Minutes (00-59)
    UTD = Unable to Determine

    Notes for Abstraction:

    Suggested Data Sources:

    Guidelines for Abstraction

    Inclusion:

          Note: The procedure record is the priority data source.

    1. Locate an inclusion term on the procedure record. If an inclusion term associated with a time is found on the procedure record, use that time. Use the earliest time associated with an inclusion term that represents the ICD-9-CM Principal Procedure Time.
    2. If an inclusion term associated with a time is not on the procedure record, other suggested data sources may be used in no particular order to locate an inclusion term. Use the earliest time associated with an inclusion term that represents the ICD-9-CM Principal Procedure Time.
    3. If no inclusion terms are found on any sources, beginning with the procedure record as the priority source, look for alternative terms associated with the procedure start time. If none are found, other forms can be used in no particular order. Use the earliest time that represents the ICD-9-CM Principal Procedure Time.
      • Procedure start
      • Procedure begin
      • Procedure initiated

    Exclusion: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE (for discharges on or after 10/1/2015): ICD-10-PCS Principal Procedure Time

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: ICD-10-PCS Principal Procedure Time

    Collected For: CSTK-01, CSTK-03

    Definition: The time (military time) when the principal procedure was performed

    Suggested Data Collection Question: What was the time that the principal procedure was performed?

    Format

    Length:
    5 - HH-MM (with or without colon) or UTD
    Type: Time
    Occurs: 1

    Allowable Values:

    HH = Hour (00-23)
    MM = Minutes (00-59)
    UTD = Unable to Determine

    Notes for Abstraction:

    Suggested Data Sources:

    Guidelines for Abstraction

    Inclusion:

          Note: The procedure record is the priority data source.

    1. Locate an inclusion term in a suggested data source in no particular order. Use the earliest time associated with an inclusion term that represents the ICD-10-PCS Other Procedure Time(s).
    2. If no inclusion terms are found on any suggested data source, look for alternative terms associated with the procedure start time. If none are found, other sources can be used in no particular order. Use the earliest time that represents the ICD-10-PCS Other Procedure Time(s).
      • Procedure start
      • Procedure begin
      • Procedure initiated

    Exclusion: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE ONLY (for discharges on or before 9/30/2015): ICD-9-CM Other Procedure Codes

    The other or secondary ICD-9-CM codes identifying all significant procedures other than the principal procedure.

    Allowable Values:
    Any valid procedure code as per the ICD-9-CM master code table (ICD-9-CM Full and Abbreviated Code Titles):
    http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html

    Suggested Data Sources:

    Inclusion Guidelines for Abstraction: For inclusion in the algorithms listed above, refer to Appendix A, for ICD-9-CM Code Tables (AMI, HF, Prev ).

    Exclusion Guidelines for Abstraction: None

    Summary of Changes

    REQUIRED FOR TJC & COMPREHENSIVE: ICD-10-PCS Other Procedure Codes

    The other or secondary ICD-10-PCS codes identifying all significant procedures other than the principal procedure.

    Allowable Values:
    Any valid procedure code as per the ICD-10-PCS master code table (PCS Long and Abbreviated Titles):
    https://www.cms.gov/Medicare/Coding/ICD10/index.html

    Notes for Abstraction:
    None

    Suggested Data Sources:

    Inclusion Guidelines for Abstraction: None

    Exclusion Guidelines for Abstraction: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE ONLY (for discharges on or before 9/30/2015): ICD-9-CM Other Procedure Dates

    The month, day, and year when the associated procedure(s) was (were) performed.

    Notes for Abstraction:

    Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commission's Data Warehouse. Use of "UTD" for ICD-9-CM Other Procedure Dates allows the case to be accepted into the warehouse.

    Suggested Data Sources:

    Inclusion Guidelines for Abstraction: None

    Exclusion Guidelines for Abstraction: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE ONLY (for discharges on or after 10/1/2015): ICD-10-PCS Other Procedure Dates

    The month, day, and year when the associated procedure(s) was (were) performed.

    Notes for Abstraction:

    Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commission's Data Warehouse. Use of "UTD" for ICD-10-PCS Other Procedure Dates allows the case to be accepted into the warehouse.

    Suggested Data Sources:

    Inclusion Guidelines for Abstraction: None

    Exclusion Guidelines for Abstraction: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE (for discharges on or before 9/30/2015): ICD-9-CM Other Procedure Times

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: ICD-9-CM Other Procedure Times

    Collected For: CSTK-01, CSTK-03

    Definition: The time (military time) when the associated procedure(s) was (were) performed.

    Suggested Data Collection Question: What were the time(s) the other procedure(s) were performed?

    Format

    Length:
    5 - HH-MM (with or without colon) or UTD
    Type: Time
    Occurs: 24

    Allowable Values:

    HH = Hour (00-23)
    MM = Minutes (00-59)
    UTD = Unable to Determine

    Notes for Abstraction:

    Suggested Data Sources:

    Guidelines for Abstraction

    Inclusion:

          Note: The procedure record is the priority data source.

    1. Locate an inclusion term on the procedure record. If an inclusion term associated with a time is found on the procedure record, use that time. Use the earliest time associated with an inclusion term that represents the ICD-9-CM Other Procedure Time(s).
    2. If an inclusion term associated with a time is not on the procedure record, other suggested data sources may be used in no particular order to locate an inclusion term. Use the earliest time associated with an inclusion term that represents the ICD-9-CM Other Procedure Time(s).
    3. If no inclusion terms are found on any sources, beginning with the procedure record as the priority source, look for alternative terms associated with the procedure start time. If none are found, other forms can be used in no particular order. Use the earliest time that represents the ICD-9-CM Other Procedure Time(s).
      • Procedure start
      • Procedure begin
      • Procedure initiated

    Exclusion: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE (for discharges on or after 10/1/2015): ICD-10-PCS Other Procedure Times

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: ICD-10-PCS Other Procedure Times

    Collected For: CSTK-01, CSTK-03

    Definition: The time (military time) when the associated procedure(s) was (were) performed.

    Suggested Data Collection Question: What were the time(s) the other procedure(s) were performed?

    Format

    Length:
    5 - HH-MM (with or without colon) or UTD
    Type: Time
    Occurs: 24

    Allowable Values:

    HH = Hour (00-23)
    MM = Minutes (00-59)
    UTD = Unable to Determine

    Notes for Abstraction:

    Suggested Data Sources:

    Guidelines for Abstraction

    Inclusion:

          Note: The procedure record is the priority data source.

    1. Locate an inclusion term in a suggested data source in no particular order. Use the earliest time associated with an inclusion term that represents the ICD-10-PCS Other Procedure Time(s).
    2. If no inclusion terms are found on any suggested data source, look for alternative terms associated with the procedure start time. If none are found, other sources can be used in no particular order. Use the earliest time that represents the ICD-10-PCS Other Procedure Time(s).
      • Procedure start
      • Procedure begin
      • Procedure initiated

    Exclusion: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE (for discharges on or before 9/30/2015): What was the ICD-9-CM diagnosis code selected as the admitting diagnosis for this patient?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Admitting Diagnosis

    Collected For: CSTK-04

    Definition: The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code associated with the diagnosis established at the time of the patients admission to the hospital.

    Suggested Data Collection Question: What was the ICD-10-CM diagnosis code selected as the admitting diagnosis for this record?

    Format

    Length:
    6 (with or without decimal point)
    Type: Alphanumeric
    Occurs: 1

    Allowable Values: Any valid diagnosis code as per the ICD-10-CM master code table (Code Descriptions in Tabular Order): https://www.cms.gov/Medicare/Coding/ICD10/index.html

    Notes for Abstraction:

    Suggested Data Sources:

    Guidelines for Abstraction

    Inclusion: None

    Exclusion: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE (for discharges on or after 10/1/2015): What was the ICD-10-CM diagnosis code selected as the admitting diagnosis for this patient?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Admitting Diagnosis

    Collected For: CSTK-04

    Definition: The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code associated with the diagnosis established at the time of the patients admission to the hospital.

    Suggested Data Collection Question: What was the ICD-10-CM diagnosis code selected as the admitting diagnosis for this record?

    Format

    Length:
    3-7 (without decimal point or dot; upper or lower case)
    Type: Character

    Occurs: 1

    Allowable Values: Any valid ICD-10-CM diagnosis code

    Notes for Abstraction:

    Suggested Data Sources:

    Guidelines for Abstraction

    Inclusion: None

    Exclusion: None

    Summary of Changes


    Discharge Diagnoses

    REQUIRED FOR STROKE, COVERDELL, MaRISS: ICD-9-CM discharge diagnosis related to stroke

    Enter the diagnosis code that describes the stroke or TIA-related condition for this episode of care. The code entered here will describe the Final clinical diagnosis related to stroke selected on the Admin Tab of the PMT.

    If the patient was treated for a stroke or TIA condition, but no code has been assigned contact your hospital’s coding department regarding code assignment.

    Summary of Changes

    REQUIRED FOR STROKE, COVERDELL, MaRISS: No Stroke or TIA related ICD-9 code present

    Check this box if none of the Principal or Secondary ICD-9 codes are related to stroke or TIA. If the ICD-9 codes do not match the clinical hospital diagnosis related to stroke, then review the case with your Stroke Champion or administrator responsible for assigning ICD-9 codes.

    Summary of Changes

    OPTIONAL FOR COVERDELL ONLY: ICD-10-CM discharge diagnosis related to stroke

    Enter the diagnosis code that describes the stroke or TIA-related condition for this episode of care. The code entered here will describe the Final clinical diagnosis related to stroke selected on the Admin Tab of the PMT.

    If the patient was treated for a stroke or TIA condition, but no code has been assigned contact your hospital’s coding department regarding code assignment.

    Summary of Changes

    OPTIONAL FOR COVERDELL ONLY: No Stroke or TIA related ICD-10-CM code present

    Check this box if none of the Principal or Secondary ICD-10-CM codes are related to stroke or TIA. If the ICD-10-CM codes do not match the clinical hospital diagnosis related to stroke, then review the case with your Stroke Champion or administrator responsible for assigning ICD-10-CM codes.

    Summary of Changes

    Admission Tab:

    Arrival and Admission Information

    During this hospital stay, was the patient enrolled in a clinical trial in which patients with the same condition as the measure set were being studied (i.e. STK, VTE)?

    Required for TJC, GWTG- Stroke, And COVERDELL users (used as a standard exclusion in measures)

    Collected For: CSTK-04, CSTK-06, STK

    Definition: Documentation that during this hospital stay the patient was enrolled in a clinical trial in which patients with the same condition as the measure set were being studied (i.e. STK, VTE).

    Format:

    Length: 1

    Type: Alphanumeric

    Occurs: 1

    Allowable Values:

    Notes for Abstraction:

  • To select "Yes" to this data element, BOTH of the following must be true:
    1. There must be a signed consent form for clinical trial. For the purposes of abstraction, a clinical trial is defined as an experimental study in which research subjects are recruited and assigned a treatment/intervention and their outcomes are measured based on the intervention received.  Treatments/interventions most often include use of drugs, surgical procedures, and devices.  Often a control group is used to compare with the treatment/intervention. Allocation of different interventions to participants is usually randomized.
    2. There must be documentation on the signed consent form that during this hospital stay the patient was enrolled in a clinical trial in which patients with the same condition as the measure set were being studied (i.e. STK, VTE) . Patients may either be newly enrolled in a clinical trial during the hospital stay or enrolled in a clinical trial prior to arrival and continued active participation in that clinical trial during this hospital stay.

    In the following situations, select "No":

    1. There is a signed patient consent form for an observational study only. Observational studies are non-experimental and involve no intervention (e.g., registries).  Individuals are observed (perhaps with lab draws, interviews, etc.), data is collected, and outcomes are tracked by investigators. Although observational studies may include the assessment of the effects of an intervention, the study participants are not allocated into intervention or control groups.
    2. It is not clear whether the study described in the signed patient consent form is experimental or observational.
    3. It is not clear which study population the clinical trial is enrolling . Assumptions should not be made if it is not specified.

    STK: Only capture patients enrolled in clinical trials studying patients with stroke. Only acceptable data sources: Signed consent form for clinical trial

    Suggested Data Sources:

    Only acceptable data sources: Signed consent form for clinical trial

    Inclusion Guidelines for Abstraction: None

    Summary of Changes

    REQUIRED for TJC, COMPREHENSIVE & COVERDELL: Was this patient admitted for the sole purpose of performance of elective carotid intervention?

    Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

    Documentation demonstrates that the current admission is solely for the performance of an elective carotid intervention (e.g., elective carotid endarterectomy, angioplasty, carotid stenting).

    Notes for Abstraction

    Suggested Data Sources: PHYSICIAN/APN/PA DOCUMENTATION ONLY

    • History and physical
    • OR report
    • Physician orders
    • Progress notes

    Guidelines for Abstraction:

    Inclusion

    Exclusion

    Patients with ICD-10-PCS procedure codes on Table 8.3 Carotid Intervention Procedures, if medical record documentation states that the patient was admitted for the elective performance of the procedure. Refer to Appendix A, Table 8.3 Carotid Intervention Procedures for examples of acceptable ICD-9-CM procedure codes.

    Elective
    o Anticipated
    o Asymptomatic
    o Evaluation
    o Non-emergent
    o Planned
    o Pre-admission
    o Pre-arranged
    o Pre-planned
    o Pre-scheduled
    o Previously arranged
    o Prophylactic
    o Scheduled
    o Work-up

    Patients with ICD-10-PCS procedure codes on Table 8.3 Carotid Intervention Procedures, if medical record documentation indicates that the patient is also being treated for an acute stroke during this hospitalization. Refer to Appendix A, Table 8.3 Carotid Intervention Procedures.

     

    Summary of Changes

    REQUIRED: Patient location when stroke symptoms discovered (Where was the patient when stroke was detected or when symptoms were discovered?)

    Indicate the type of facility or setting from which the patient came from when stroke like symptoms were discovered.

    Notes for Abstraction

    Pre-hospital Data, Admission Data

    Summary of Changes

    REQIRED: How patient arrived at your hospital

    Definition: Recording the method of transfer (private vehicle, ground or air ambulance), distance traveled, and duration of transfer is useful for determining patient and system costs. For this element, indicate the type of transport used to bring the patient to your facility.

    Data Collection Question: How did the patient get to your hospital for treatment of their stroke?

    Allowable Values:

    Notes for Abstraction:


    Data Sources:
  • Pre-hospital Data
  • Admission Data
  • Referring hospital discharge date/time

    Optional field
    This field is enabled when How patient arrived at your hospital = Transfer from other hospital

    Definition: Tracking transfers between facilities is important for understanding the flow of patients, cost structure, and eventual outcomes. Time of transfer, destination facility, and time of arrival should be recorded for all such cases. For this element, record the date and time the patient left the facility of the referring hospital.

    Data Collection Question: What was the date/time patient was discharged from the referring hospital to your hospital?

    Format:

    Length: 15 MM-DD-YYYY :HH-MM (with or without colon & includes dashes) or Unkonwn

    Type: Date and Time

    Occurs: 1


    Allowable Values:

    Date

    MM = Month (01-12)

    DD = Day (01-31)

    YYYY = Year (2012-Current Year)

    UTD = Unknown

    Time

    HH = Hour (00-23)

    MM = Minutes (00-59)

    UTD = Unknown


    Examples:

    Midnight = 00:00

    Noon = 12:00

    5:31 am = 05:31

    5:31 pm = 17:31

    11:59 am = 11:59

    11:59 pm = 23:59


    Notes for Abstraction: Suggested Data Source:

    Specify the referring hospital name

    Optional field Note: This field is enabled when How patient arrived at your hospital = Transfer from other hospital

    Definition: Specify the name of the referring hospital that transferred the patient to your hospital.

    Data Collection Question: What was the name of the hospital that transferred the patient to your hospital?

    Format: Single-select

    Allowable Values: varies - list but be customized by user. Please refer to Notes for Abstraction below for guidance in the populating field. Allowable Values:

    Notes for Abstraction:

    For this field to display the list of hospitals, you must pre-populate which hospitals to display for your sit e from the American Hospital Association ID lookup tool. Follow the steps below to populate the list of hospitals for your site:

    1. Select the My Account Tab on the far right of the screen
    2. Select Manage Code List
    3. Select the AHA ID List hyperlink
    4. Select New Code hyperlink
    5. A lookup table displays the follow the following columns: Hospital Name, AHA ID, City, State, or Zip Code.
      1. To view the list of hospitals, you must enter data for any of the two fields (hospital name, address, ID, city, state, or zip code).
      2. Results displayed are dependent on the search criteria.
      3. Please note, the AHA ID list is updated weekly. However, it will be updated in the PMT every quarter.
    6. Select the hospital(s) from the lookup tool and then select the Save Selection button to add the hospital to your dropdown list.
    7. Repeat steps 5 - 6 until you have the list of hospitals most frequently transferred/received patients.

    Suggested Data Source:

    Referring hospital arrival date/time

    Optional field Note: This field is enabled when How patient arrived at your hospital = Transfer from other hospital Definition: The date and time the patient first arrived at the referring hospital (1st hospital). This date/time may be obtained by the receiving hospital (2nd hospital) by either reviewing the EMS run sheet or from the referring hospital. Data Collection Question: What is the date/time patient arrived at the referring hospital (1st hospital) for this episode of care? Format:

    Length: 15 MM-DD-YYYY :HH-MM (with or without colon & includes dashes) or Unkonwn

    Type: Date and Time

    Occurs: 1


    Allowable Values:

    Date

    MM = Month (01-12)

    DD = Day (01-31)

    YYYY = Year (2012-Current Year)

    UTD = Unknown

    Time

    HH = Hour (00-23)

    MM = Minutes (00-59)

    UTD = Unknown


    Examples:

    Midnight = 00:00

    Noon = 12:00

    5:31 am = 05:31

    5:31 pm = 17:31

    11:59 am = 11:59

    11:59 pm = 23:59


    Notes for Abstraction:
    Suggested Data Source

    Select reason(s) for why patient transferred:

    Appears for all users - only complete this field if you are the referring hospital and transferring the patient to another hospital. Note: Required in patients who have "Not Admitted = Yes" and "Reason not admitted" = "Transferred from your ED to another acute care hospital"

    Definition: The reason associated with the acute stroke patient transferred from the referring hospital emergency department (ED) to a different hospital (e.g. Primary Stroke Center, Comprehensive Stroke Center). Intent of the element is to determine the transfer rates and reason for transfer and how it may affect patient outcomes.

    Question: What was the reason for transferring the patient to your hospital? Check all applicable fields.

    Format: Multi-select field

    Allowable Values:

    Notes for Abstraction:

    Summary of Changes

    Was the patient an ED patient at the facility?

    REQUIRED FOR TJC, COMPREHENSIVE & ASR

    Definition: Patient received care in a dedicated emergency department of the facility.

    Collected For: ASR-IP-1, CSTK-01, CSTK-03, CSTK-04

    Data Collection Question: Was the patient an ED patient at the facility?

    Format:

    Length: 1

    Type: Alphanumeric

    Occurs: 1

    Allowable Values:
    Y (Yes) There is documentation the patient was an ED patient.

    N (No) There is no documentation the patient was an ED patient, OR unable to determine from medical record documentation.
    Notes for Abstraction:

    ED: (Abstraction Guidelines for ED Measures Only)



    Suggested Data Sources:

    Guidelines for Abstraction:


    Inclusion: None
    Exclusion:

    Was the patient a direct admission to the hospital?

    Collected For: CSTK-01, CSTK-03

    Definition: Patient transferred from another acute care facility and taken to the operating room or interventional suite prior to hospital admission, or admitted directly to intensive care or other unit of the hospital.

    Suggested Data Collection Question: Was the patient a direct admission to the hospital?

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:
    Y (Yes) There is documentation the patient was a direct admission to the hospital.

    N (No) There is no documentation the patient was a direct admission to the hosptial, OR unable to determine from medical record documentation.

    Notes for Abstraction:

    Suggested Data Sources:

    Summary of Changes

    Initial Admitting Service

    Collected For: GWTG,ICH
    Definition: Documentation of the initial admitting service.
    Question: What was the initial admitting service?
    Format: Single Select
    Allowable Values:
    • Neurology
    • Neurosurgery
    • Neurocritical Care
    • Medicine
    • Surgery
    • Other: ____________________

    Notes for Abstraction:
    • Select the initial service in which the patient was admitted under.
    • If other is selected, please specify the service.
    Suggested Data Sources:
    • Admission Data
    • Hospitalization Data

    Additional Notes / Guidelines for Abstraction: N/A

    In which settings were care delivered? Select all that apply.

    Collected For: GWTG,ICH
    Definition: Documentation of all settings in which care was delivered.
    Question: In which settings were care delivered?
    Format: Multi-Select
    Allowable Values:
    • Neuro/ Neurosurgery ICU
    • Other ICU
    • Stroke Unit (Non-ICU)
    • General Care Floor
    • Observation
    • Other: ____________________

    Notes for Abstraction:
    • Select all settings in which care was delivered.
    • If other is selected, please specify the setting.
    Suggested Data Sources:
    • Admission Data
    • Hospitalization Data

    Additional Notes / Guidelines for Abstraction: N/A

    If the patient was not cared for in a dedicated stroke unit, was a formal inpatient consultation from a stroke expert obtained?

    Collected For: GWTG,ICH
    Definition: Documentation that a stroke expert was consulted in the event that a patient was not cared for in a dedicated stroke unit.
    Question: If the patient was not cared for in a dedicated stroke unit, was a formal inpatient consultation from a stroke expert obtained?
    Format: Single Select
    Allowable Values:
    • Yes
    • No
    • ND

    Notes for Abstraction:
    • If General Care Floor, Observation or Other non-stroke settings were selected for the delivery of care and there is documentation of a stroke consult, select Yes.
    • Consultation from a stroke expert may include:
      • Telestroke
      • Neurology Consult
      • Neurosurgery Consult
      • Vascular Neurology Consult
      • Neuroradiology Consult

      Suggested Data Sources:
      • Pre-Hospital Data
      • Admission Data
      • Hospitalization Data

      Additional Notes / Guidelines for Abstraction: N/A

      Summary of Changes

      REQUIRED: Advanced notification by EMS or Mobile Stroke Unit?

      Definition: EMS personnel should provide prehospital notification to the receiving hospital that a suspected stroke patient is en route so that the appropriate hospital resources may be mobilized before patient arrival. For this element, record if EMS personnel or personnel in a Mobile Stroke Unit notified the receiving hospital prior to the arrival of possible stroke patient.

      Allowable Values:
      • Yes
      • No/ND
      • N/A

      Notes for Abstraction:
      • Yes: EMS notified the receiving hospital prior to arrival
      • To select Yesthere must be explicit documentation that advanced notification by EMS included that the patient was a suspected stroke.
      • The following language is sufficient to identify patients with suspected stroke; any use of the word "stroke" or any documentation of signs & symptoms consistent with stroke is acceptable:
      • N/A: the patient did not arrive via EMS
        • Sudden numbness or weakness of face, arm or leg - especially on one side of the body.
        • Sudden confusion/altered mental status, trouble speaking or understanding.
        • Sudden trouble seeing in one or both eyes.
        • Sudden trouble walking dizziness/vertigo, loss of balance or coordination.
        • Sudden severe headache with no known cause.
        • Positive stroke screen
      • No/ND: EMS either did not pre-notify the receiving hospital or there is no documentation regarding EMS pre-notification.
      • N/A: the patient did not arrive via EMS or Mobile Stroke Unit


      Example:
      Patient 010a was picked up by the EMTs at 0810. On their departure to the hospital at 0820, they call the ED to inform them they are bringing in a potential stroke patient. They arrive at the ED at 0830. The hospital was therefore pre-notified that a potential stroke patient was arriving.

      Suggested Data Sources:

      Pre-hospital Data
      Admission Data

      Summary of Changes

      Admission Data

      Summary of Changes

      OPTIONAL: Physician/Provider NPI (Physician/Service) (custom field per site)

      Use this field to capture a physician name or identifier in order to track physicians' involvement.

      National Provider ID (NPI) is assigned by CMS to all physicians. You do not need to know NPIs for your physicians, but rather, when adding or editing physicians in your Physician/Provider NPI list, a lookup tool will let you search by name, and assign the correct NPI for you. For more information on adding a physician to the dropdown list, contact your administrator or the Quintiles RWLPR Technical Support.

      Physician/Provider NPI is an optional field for each institution and can be assigned based on the Continuous Quality Improvement (CQI) needs of the institution.

      Summary of Changes


      Telestroke

      Note: To enable the telestroke elements to appear for your site, you must first update the site settings. Follow the steps below to enable or disable the telestroke elements.

      1. On the Community Page, select Stroke Site Characteristics.
      2. System displays the Organization Information Page. Scroll to the bottom of the page.
      3. Navigate to the last section, Settings.
      4. Indicate if at the site-level your hospital is primarily a provider or recipient of telestroke consultation.
        1. Select Provider of telestroke consultation if you are a referral center that provides telestroke services and happen to cover some of your own ED shift with your telestroke providers.
        2. Select Recipient of telestroke consultation if your hospital primarily receives telestroke consultation for your patients and tend to transfer patients somewhere else.

      One enabled, you will be able to view the Telestroke fields in the PMT.


      REQUIRED FOR COVERDELL ONLY: TeleStroke Consultation Performed

      Collected For: GWTG

      Definition: Telemedicine (telestroke) is an integrated audio and/ or visual remote assessment. Ability to provide expertise virtually to diagnose, monitor, and/ or treat patients (e.g. recommend therapies) with 24/7 coverage in a variety of settings. Some consultations may begin with audio only and add video only when patient examination is needed to address the consultation question. Review of lab data or neuroimaging is often involved, whether or not video is deployed.

      Question: Was telestroke consultation performed at your hospital for this episode of care?

      Format: Single Select

      Allowable Values:

      • Yes, the patient received telestroke consultation from my hospital staff when the patient was located at another hospital.
      • Yes, the patient received telestroke consultation from someone other than my staff when the patient was located at another hospital.
      • Yes, the patient received telestroke consultation from a remotely located expert when the patient was located at my hospital.
      • No telestroke consult performed
      • Not documented

      Notes for Abstraction:

      • Yes, the patient received telestroke consultation from my hospital staff when the patient was located at another hospital (for use by hub).
      • Yes, the patient received telestroke consultation from someone other than my staff when the patient was located at another hospital (for use by hub).
      • Yes, the patient received telestroke consultation from a remotely located expert when the patient was located at my hospital (for use by hub or spoke). A CSC might select this if the CSC stroke team neurologist takes call from home at nights and uses telestroke to assess patients who are located in the CSC ED or inpatient floors. This has been increasingly implemented during the COVID crisis or at centers where the stroke expert lives far from the hospital.
      • No telestroke consult performed for this episode of care.
      • No telestroke consult performed for this episode of care.

      Suggested Data Sources:

      • Progress Notes
      • Admission Report
      • Transfer Sheet
      • Telestroke Records or Reports

      Additional Notes / Guidelines for Abstraction: N/A


      If yes - Telestroke Delivery Method

      Collected For: GWTG

      Definition: Earlier access to stroke expertise is associated with faster alteplase initiation, which is strongly associated with improved outcomes. Additionally, studies indicate patients treated without neurologist on-site have achieved similar outcomes as those with on-site neurologist. For this element, indicate the delivery method(s) used to obtain stroke expertise for the patient to assist with decision-making.

      Question: If telestroke consult as performed, select all applicable delivery methods:

      Format: Multi-Select

      Allowable Values:

      • Interactive Video
      • Teleradiology
      • Telephone Call
      • ND

      Notes for Abstraction:

      • Most telestroke networks have the option of conducting consultations via phone, real-time audio/video, or both, with the method of consult depending on patient factors (e.g., intra- venous alteplase eligibility) or technology availability (network or camera failures). Therefore, select all applicable options used for this admission.
      • Interactive Video: Defined as the ability to provide two-way real-time audiovisual conferencing and share images. Allows clinicians to perform consults as if they were present in the room.
      • Teleradiology: Defined as the ability to obtain radiographic images at one location and transmit them to another for diagnostic and consultative purposes. Used by stroke specialists to read non-enhanced CT scans of the brain to determine intravenous alteplase eligibility.
      • Telephone Call: Telephone consultations with a stroke specialist as part of as ancillary, adjunctive, supplemental, or back-up modality.
      • If there is no documentation of which modality used or cannot be determined from the medical record, select "ND" for not documented.

      Suggested Data Sources:

      • Progress Notes
      • Admission Report
      • Transfer Sheet
      • Telestroke Records or Reports

      Additional Notes / Guidelines for Abstraction: N/A


      If yes - Type of Telestroke Provider

      Collected For: GWTG

      Definition: Documentation of the type of telestroke provider.

      Question: What was the type of Telestroke provider?

      Format: Single Select

      Allowable Values:

      • Hospital Based (In-State)
      • Hospital Based (Out of State)
      • Private Provider (Independent)

      Notes for Abstraction:

      • Select a Hospital Based provider (in or out of state) if the telestroke consultant is based at another hospital
      • Select Private Provider if the telestroke consultant is based out of or contacted through a private company.

      Suggested Data Sources:

      • Progress Notes
      • Admission Report
      • Transfer Sheet
      • Telestroke Records or Reports

      Additional Notes / Guidelines for Abstraction: N/A


      Who provided Telestroke service?

      Collected For: GWTG

      Definition: Documentation of who provided the telestroke service - this can be identified as a specific physician, group of physicians, hospital, or private company.

      Question: Who provided Telestroke service?

      Format: Drop Down - Site Created List

      Allowable Values:

      • Drop Down - Site Created List

      Notes for Abstraction:

      • Providers will appear in the drop-down list based on the list created by each site with their unique telestroke providers

      Suggested Data Sources:

      • Progress Notes
      • Admission Report
      • Transfer Sheet
      • Telestroke Records or Reports

      Additional Notes / Guidelines for Abstraction: N/A


      Did the Telestroke consult recommend transfer?

      Collected For: GWTG

      Definition: Documentation of whether or not the Telestroke consultant recommended the patient be transferred for a higher level of care.

      Question: Did the Telestroke consultant recommend transfer?

      Format: Single Select

      Allowable Values:

      • Yes
      • No
      • ND

      Notes for Abstraction:

      • Select Yes if there is documentation that the telestroke consultation resulted in a recommendation for transfer.
      • Select No if there is the telestroke consultation did not result in a recommendation for transfer.
      • Select ND if there is no documentation whether or not the consultation resulted in a recommendation for transfer.

      Suggested Data Sources:

      • Progress Notes
      • Admission Report
      • Transfer Sheet
      • Telestroke Records or Reports

      Additional Notes / Guidelines for Abstraction: N/A


      Patient Transfer Status after Telestroke Consult

      Collected For: GWTG

      Definition: Documentation of the level of the destination facility the patient was transferred to following the telestroke consult. Stroke centers are defined as certified as TJC or Equivalent designation.

      Question: What was the patient?#8364;™s transfer status after Telestroke consult (TJC or Equivalent)?

      Format: Single Select

      Allowable Values:

      • Not Transferred
      • Transferred to PSC
      • Transferred to TSC
      • Transferred to CSC
      • Transferred to Unknown

      Notes for Abstraction:

      • Select the type of facility that best represents the level of care the patient was transferred to based on the recommendation of the telestroke consultant
      • Facility types can be The Joint Commission certified or equivalent
      • If documentation is unclear, select Transferred to Unknown

      Suggested Data Sources:

      • Progress Notes
      • Admission Report
      • Transfer Sheet
      • Telestroke Records or Reports

      Additional Notes / Guidelines for Abstraction: N/A


      Destination Facility

      Collected For: GWTG

      Definition: Documentation of a description of the facility the patient is transferred to following telestroke consult.

      Question: Which option best describes the destination facility for the transferred patient?

      Format: Single Select

      Allowable Values:

      • Hospital where the telestroke consultant primarily practices
      • Hospital unrelated to the telestroke consultant and outside of my health system
      • Hospital unrelated to the telestroke consultant but within my health system
      • Unable to determine from medical record

      Notes for Abstraction:

      • Select the option that best describes the facility the patient was transferred to following telestroke consult.
      • Hospitals are considered to be within your health system if they are owned or operated by the same entity as your hospital, or have a shared facility system name

      Suggested Data Sources:

      • Progress Notes
      • Admission Report
      • Transfer Sheet
      • Telestroke Records or Reports

      Additional Notes / Guidelines for Abstraction: N/A


      Did Telestroke consultation result in thrombolytic administration at the referring site?

      Collected For: GWTG

      Definition: Documentation that the telestroke consultation resulted in thrombolytic administration.

      Question: Did Telestroke consultation result in thrombolytic administration at the referring site?

      Format: Single Select

      Allowable Values:

      • Yes
      • No
      • ND

      Notes for Abstraction:

      • Select Yes if documentation is clear that the telestroke consult directly resulted in the administration of thrombolytic therapy.
      • Do not select Yes if the decision to administer thrombolytic therapy and the infusion was started prior to teleconsultation

      Suggested Data Sources:

      • Progress Notes
      • Admission Report
      • Transfer Sheet
      • Telestroke Records or Reports

      Additional Notes / Guidelines for Abstraction: N/A


      Telestroke Time Tracker

      Date/ Time of First Telestroke Consultation Request

      Formerly Labeled: If Yes, Telestroke Date/ Time

      Collected For: GWTG

      Definition: The date and time the telestroke consult was requested.

      Question: If telestroke consult was performed, enter date and time of the request of a consultation with the telestroke provider:

      Format: MM/DD/YYYY; HH:MM; Drop Down for Alternative Formats

      Allowable Values:

      • Date: MM/DD/YYYY
        • MM = Month (01-12)
        • DD = Day (01-31)
        • YYYY = Year (2012 - Current Year)
      • Time: 24 Hour Clock (Military Time)
        • HH = Hour (00-23)
        • MM = Minutes (00-59)
      • Unknown

      Notes for Abstraction:

      • Time must be recorded in military time format. Except for Midnight and Noon
        • If the time is in the AM, conversion is not required
        • If the time is in the PM, add 12 to the clock time hour
      • If multiple modalities used, indicate the initial contact time with the consulting stroke specialist for the earliest modality used.

      Suggested Data Sources:

      • Progress Notes
      • Admission Report
      • Transfer Sheet
      • Telestroke Records or Reports

      Additional Notes / Guidelines for Abstraction: N/A


      Date/ Time Telestroke Response

      Collected For: GWTG

      Definition: The earliest recorded date and time the telestroke consultant responded.

      Question: If telestroke consult performed, enter date and time of the telestroke provider's response

      Format: MM/DD/YYYY; HH:MM; Drop Down for Alternative Formats

      Allowable Values:

      • Date: MM/DD/YYYY
        • MM = Month (01-12)
        • DD = Day (01-31)
        • YYYY = Year (2012 - Current Year)
      • Time: 24 Hour Clock (Military Time)
        • HH = Hour (00-23)
        • MM = Minutes (00-59)
      • Unknown

      Notes for Abstraction:

      • Time must be recorded in military time format. Except for Midnight and Noon
        • If the time is in the AM, conversion is not required
        • If the time is in the PM, add 12 to the clock time hour
      • If multiple modalities used, indicate the initial contact time with the consulting stroke specialist for the earliest modality used.

      Suggested Data Sources:

      • Progress Notes
      • Admission Report
      • Transfer Sheet
      • Telestroke Records or Reports

      Additional Notes / Guidelines for Abstraction: N/A


      Date/ Time Start of Telestroke Video Session

      Collected For: GWTG

      Definition: The date and time the telestroke video session began

      Question: If telestroke consult performed, enter date and time of the start of the telestroke video session

      Format: MM/DD/YYYY; HH:MM; Drop Down for Alternative Formats

      Allowable Values:

      • Date: MM/DD/YYYY
        • MM = Month (01-12)
        • DD = Day (01-31)
        • YYYY = Year (2012 - Current Year)
      • Time: 24 Hour Clock (Military Time)
        • HH = Hour (00-23)
        • MM = Minutes (00-59)
      • Unknown

      Notes for Abstraction:

      • Time must be recorded in military time format. Except for Midnight and Noon
        • If the time is in the AM, conversion is not required
        • If the time is in the PM, add 12 to the clock time hour
      • If multiple modalities used, indicate the initial contact time with the consulting stroke specialist via video. This is the start of the actual video session with both parties present, and not the time by phone call or other means, or the time at which the teleconsultant initiated the software for video.

      Suggested Data Sources:

      • Progress Notes
      • Admission Report
      • Transfer Sheet
      • Telestroke Records or Reports

      Additional Notes / Guidelines for Abstraction: N/A


      Date/ Time Decision to Administer Thrombolytic (By Telestroke)

      Collected For: GWTG

      Definition: The date and time the telestroke consultant recommended thrombolytic therapy for the patient

      Question: If telestroke consult performed, enter date and time of the decision to administer thrombolytics.

      Format: MM/DD/YYYY; HH:MM; Drop Down for Alternative Formats

      Allowable Values:

      • Date: MM/DD/YYYY
        • MM = Month (01-12)
        • DD = Day (01-31)
        • YYYY = Year (2012 - Current Year)
      • Time: 24 Hour Clock (Military Time)
        • HH = Hour (00-23)
        • MM = Minutes (00-59)
      • Unknown

      Notes for Abstraction:

      • Time must be recorded in military time format. Except for Midnight and Noon
        • If the time is in the AM, conversion is not required
        • If the time is in the PM, add 12 to the clock time hour
      • If multiple modalities used, indicate the initial contact time with the consulting stroke specialist for the earliest modality used.

      Suggested Data Sources:

      • Progress Notes
      • Admission Report
      • Transfer Sheet
      • Telestroke Records or Reports

      Additional Notes / Guidelines for Abstraction: N/A


      Telestroke Additional Comments

      Collected For: GWTG

      Definition: General comments or notes related to the telestroke consultation.

      Question: Enter any additional comments or notes related to telestroke.

      Format: Text Field

      Allowable Values:

      • 200-character text

      Notes for Abstraction: N/A

      Suggested Data Sources: N/A

      Additional Notes / Guidelines for Abstraction: N/A


      Demographics Tab

      REQUIRED: Sex

      Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

      The patient's documented sex on arrival at the hospital.

      Data Collection Question: What is the patient's sex?

      Allowable Values:

      • Male
      • Female
      • Unknown

      Notes for Abstraction:

      • Collect the documented patient's sex at admission or the first documentation after arrival.
      • Consider the sex to be unable to be determined and select "Unknown" if:
        • The patient refuses to provide their sex.
        • Documentation is contradictory.
        • Documentation indicates the patient is a Transsexual.
        • Documentation indicates the patient is a Hermaphrodite.

        Suggested Data Sources:

        • Consultation notes
        • Emergency department record
        • Face sheet
        • History and physical
        • Nursing admission notes
        • Progress notes
        • UB-04

        Additional Notes/ Guidelines for Abstraction: N/A

      REQUIRED: Patient Gender Identity

      Collected For: GWTG

      Definition:The gender identity, self-identified by the patient. This may or may not match sex assigned at birth.

      Data Collection Question: What is the patient's self-identified gender?

      Format:Single Select

      Allowable Values:

      • Male
      • Female
      • Female-to-Male (FTM)/ Transgender Male/ Trans Male
      • Male-to-Female (MTF)/ Transgender Female/ Trans Female
      • Genderqueer, neither exclusively male nor female
      • Additional gender category or other: __________________
      • Did not disclose

      Notes for Abstraction:

        • Select "Female-to-Male (FTM)/Transgender Male/Trans Man" if the patient was assigned the female sex at birth but currently identifies on the male spectrum. (Also known as a transgender man)
        • Select "Male-to-Female (MTF)/Transgender Female/Trans Woman" if the patient was assigned the male sex at birth but identifies on the female spectrum. (Also known as a transgender woman).
        • Select "Genderqueer, neither exclusively male nor female" if the patient's sex identity and/or gender expression falls outside the binary categories of male or female. Patient may define their sex as falling somewhere in between male and female, or they may define it as wholly different from these terms.
        • Select "Additional gender category or other. ________" if the patient self-identifies with any other gender that is not listed above, then specify in the blank section provided.
        • Select "Additional gender category or other. ________" if the patient self-identifies with any other gender that is not listed above, then specify in the blank section provided.
        • References:
          • CDC Terminology: Derived from APA's Definitions Related to Sexual Orientation and Gender Diversity and WHO's Gender, Equity and Human Rights – https://www.cdc.gov/healthyyouth/terminology/sexual-and-gender-identity-terms.htm
          • ONC (HealthIT.gov): Includes LOINC and SNOMED Codes – Representing Sexual Orientation and Gender Identity – https://www.healthit.gov/isa/section/sex-birth-sexual-orientation-and-gender-identity
          • US Dept. Of Health & Human Services/CDC – Sexual Orientation Survey: A Quality Assessment – https://www.cdc.gov/nchs/data/series/sr_02/sr02_169.pdf

          Suggested Data Sources:

          • Admission Data
          • Care Plans
          • Transfer Notes
          • Face sheet
          • History and Physical
          • Emergency Department Records

          Additional Notes/ Guidelines for Abstraction:N/A

      REQUIRED: Patient Indentified Sexual Orientation

      Collected For: GWTG

      Definition:The self-reported sexual orientation of the patient. Also defined as the gender(s) to which a person is physically attracted.

      Data Collection Question: What is the patient's self-identified sexual orientation?

      Format:Single Select

      Allowable Values:

      • Straight
      • Lesbian or gay
      • Bisexual
      • Queer, pansexual, and/or questioning
      • Something else; please specify: __________________
      • Don't know
      • Declined to answer

      Notes for Abstraction:

        • Straight or heterosexual – Select this option if the patient reports an orientation of sexual attraction to members of the opposite sex.
        • Lesbian or gay – Select this option if the patient reports an orientation of sexual attraction to members of the same sex.
        • Bisexual – Select this option if the patient reports an orientation of sexual attraction to both males and females, or where the sexual attraction is not exclusive to people of one particular gender.
        • Queer, pansexual, and/or questioning – Select this option if the patient reports any of these options:
          • Pansexual – Refers to a person who is sexually and/or romantically attracted to persons of any gender identity and/or biological sex. Pansexual people may also refer to themselves as gender-blind.
          • Queer – Refers to a person whose attractions and/or romantic relationships are not heterosexual or whose gender identities are not the same as those assigned at birth.
          • Questioning – This term describes someone who is questioning their sexual orientation or gender identity
        • References:
          • CDC Terminology: Derived from APA's Definitions Related to Sexual Orientation and Gender Diversity and WHO's Gender, Equity and Human Rights – https://www.cdc.gov/healthyyouth/terminology/sexual-and-gender-identity-terms.htm
          • ONC (HealthIT.gov): Includes LOINC and SNOMED Codes – Representing Sexual Orientation and Gender Identity – https://www.healthit.gov/isa/section/sex-birth-sexual-orientation-and-gender-identity
          • US Dept. Of Health & Human Services/CDC – Sexual Orientation Survey: A Quality Assessment - https://www.cdc.gov/nchs/data/series/sr_02/sr02_169.pdf

          Suggested Data Sources:

          • Admission Data
          • Care Plans
          • Transfer Notes
          • Face sheet
          • History and Physical
          • Emergency Department Records

          Additional Notes/ Guidelines for Abstraction:N/A

      REQUIRED: Date of Birth

      Collected For: All records

        Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

        The month, day, and year the patient was born.

        Note:

      • Patient's age (in years) is calculated by Admission Date minus Birthdate. The algorithm to calculate age must use the month and day portion of admission date and birthdate to yield the most accurate age.
      • For Get With The Guidelines, if entering a “Not Admitted” patient, patient’s age is calculated by Arrival Date minus Birthdate.
      • Data Collection Question: What is the patient's date of birth?

        Format:

        Length: 10 - MM-DD-YYYY (includes dashes)

        Type: Date

        Occurs: 1

        Allowable Values: 1

        MM = Month (0-12)

        DD = Day (01-31)

        YYYY = Year (1880-Current Year)

        Notes for Abstraction:

        Because this data element is critical in determining the population for all measures, the abstractor should NOT assume that the claim information for the birthdate is correct. If the abstractor determines through chart review that the date is incorrect, she/he should correct and override the downloaded value. If the abstractor is unable to determine the correct birthdate through chart review, she/he should default to the date of birth on the claim information.

        Suggested Data Sources:
        • Emergency department record
        • Face sheet
        • Registration form
        • UB-04

        Admission Data, UB-04, (previously UB-92)

      REQUIRED: Age

      Note: Once the date and time of admission are entered, the system will calculate the patient's age.

      Definition: Indicate the patient's age (in years) by calculating the following: Admission Date minus Birthdate.

      Data Collection Question: What is the patient's date of birth?

      Allowable Values: Numerical Value

      Notes for Abstraction:

      • If the abstractor determines through medical record review that the UB-92/UB-04 day is incorrect, she/he should correct and override the downloaded value.
      • If the abstractor is unable to determine the correct birth date through medical record review, she/he should default to the UB-92/UB-04 date of birth.

      Suggested Data Sources:

      • Emergency department record
      • UB-04, Field Location: 14

      Admission Data, UB-92/UB-04, Field Location: 14.

      OPTIONAL: Homeless

      Definition: Indicate if the patient is homeless.

      Allowable Values:

      • Checkbox - Select or leave blank

      Notes for Abstraction:

      • Select the field to indicate if the user has no home or current place of residence
      • If the Boolean field (checkbox) is selected, then the field zip code will be disabled for the user.

      Suggested Data Sources:

      • Patient
      • Patient Care Report (ePCR or PCR)

      OPTIONAL: Zip Code (Postal Code)

      Record the postal code of the patient's residence. For the United States zip codes the hyphen is implied.

      Notes for Abstraction:

      • If the patient is determined to not have a permanent residence, then the patient is considered homeless and Homeless should be checked.
      • If the patient resides in another country, the zip or postal code from that country should be entered as a string of alpha-numeric characters. E.G. the zip code for a patient who lives in Bras d'Or, Canada should have their zip code entered as "B1Y3X9" with no spaces.
      • If the postal code of the patient is unable to be determined from medical record documentation, enter the provider's postal code.
      • For Stroke CM users, this field will auto-populate Zip Code on the Core Measure Tab.
        • For submission to The Joint Commission, if the patient is not a resident of the United States, use "NONUS." Thus, if you have entered a Canadian postal code in the GWTG field which pre-populates on the Core Measures tab you must overwrite the value in this field on the Core Measures tab with "NONUS."

      https://osstatic.irp.iqvia.com/online_doc_qi/StrokePMT/coding_instruction/source.jpgAdministrative Data:UB-04, Field Location: 09 (line 2d); Medical Record: Face sheet

      Payment Source

      Indicate the health insurance payer status for this patient.

      • Medicare Title 18
      • Medicaid Title 19
      • Medicare - Private/HMO/PPO/Other
      • Medicaid - Private/HMO/PPO/Other
      • Private/HMO/PPO/Other
      • VA/CHAMPVA/Tricare
      • Self Pay/No Insurance
      • Other/Not Documented/UTD

      Notes for Abstraction:

      • Medicare Title 18 - Traditional Fee for Service Medicare parts A, B and D
      • Medicaid Title 19 - State Medicaid or Joint State/Federal Program. This program provides health insurance to individuals who have low income, including persons who are blind or disabled.
      • Medicare - Private/HMO/PPO/Other - Medicare Advantage Part C Programs
      • Medicaid - Private/HMO/PPO/Other - Medicaid Advantage Programs
      • Private/HMO/PPO/Other - Commercial insurance (Not Medicare/ Medicaid) typically tied to employer-based plans
      • If checking "Self Pay/No Insurance" or "Not Documented", then no other selections should be checked.
      • Patients may have a combination of "Medicare Title 18," "Medicaid Title 19," "Medicare - Private/ HMO/ PPO/ Other," "Medicaid - Private/HMO/PPO/Other," "Private/ HMO/ PPO/ Other" and "VA/CHAMPVA/ Tricare."
      • Socioeconomic Demographics - States may use alternative names for Medicaid within their respective states. Be mindful of your states name for medicaid (e.g., MassHealth)

      Suggested Data Sources:

      • Admission Data
      • Face Sheet
      • UB-04

      Additional Notes/ Guidelines for Abstraction: N/A


      Race and Ethnicity

      • Hispanic Ethnicity
      • Race
      • Hispanic Ethnicity

          Collected For: GWTG, STK, CSTK ASR

          Definition: Documentation that the patient is of Hispanic, Latino, or Spanish ethnicity

          Question: Is the patient of Hispanic, Latino or Spanish ethnicity?

          Format: Single Select

          Allowable Values

          • Yes - Patient is of Hispanic, Latino or Spanish ethnicity
          • No/ UTD - Patient is not of Hispanic, Latino, or Spanish ethnicity or unable to determine from medical record documentation

          Notes for Abstraction:

          The data element, Race, is required in addition to this data element.

          Suggested Data Sources:

          • Emergency department record
          • Face sheet
          • History and physical
          • Nursing admission assessment
          • Progress notes

        Additional Notes / Inclusion Guidelines for Abstraction:

        • Inclusion: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term "Spanish origin" can be used in addition to "Hispanic or Latino."

        Examples: Black-Hispanic, Chicano, Columbian, Dominican, Ecuadorian, Guatemalan, H, Hispanic, Latin American, Latino/ Latina, Mexican American, Salvadorian, Spaniard, Spanish, White-Hispanic

        OPTIONAL: If yes, specify Hispanic Ethnicity

        If the patient is of Hispanic ethnicity or Latino, select the specific sub-category (or sub-categories) identified by the patient.

        • Mexican, Mexican American, Chicano/a
        • Puerto Rican
        • Cuban
        • Another Hispanic, Latino, or Spanish Origin: The patient identified as some other Hispanic, Latino or Spanish origin not provided in the options above.

        Notes for Abstraction: If the patient did not identify a subcategory, leave this field blank

        Admission Data

        Summary of Changes

        REQUIRED: Race

        Select the patient's self-assessed race/ethnicity, or if not available, the physician or institution's assessment. Assumptions should not be made based on physical characteristics. This data allows for analysis of race-related patterns of care. If patient is multi-racial, select each race they designate. Select all that apply from the list provided. Hold down the "Ctrl" key on the keyboard to select multiple options or to deselect an option. Select all that apply from the list provided.

        • Note for TJC/CM Users: If multiple options are selected for Race on the Hospitalization tab, then the Core Measures tab data element of “Race” will not auto-populate. Please complete the Core Measures tab data element of “Race” in accordance with the Specifications Manual for National Hospital Inpatient Quality Measures which states: If documentation indicates the patient has more than one race (e.g., Black-White, Indian-White), select the first listed race.

        If the patient is Asian or Native Hawaiian/Pacific Islander, select the specific sub-category (or sub-categories) of race if known. Selection of a race sub-category is optional.

        Options include:

        • American Indian/Alaska Native - A person having origins in any of the original peoples of North and South American (including Central America) and who maintains tribal affiliation or community attachment (e.g., any recognized tribal entity in North and South America (including Central America), Native American).
        • Asian - A person having origins in any of the original peoples of the Far East, southeast Asia, or the Indian subcontinent, including for example, India, China, Philippines, Japan, Korea, Vietnam, or Other including, but not limited to Cambodia, Malaysia, Hmong, and Thailand. If Asian, select the specific sub-category (or sub-categories). Select all that apply from the list provided.
              • Asian Indian
              • Chinese
              • Filipino
              • Japanese
              • Korean
              • Vietnamese
              • Other Asian: The patient identified as some other Asian sub-category not provided in the options above or did not identify a sub-category.
        • Black or African American - A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black or African American”.
        • Native Hawaiian/Pacific Islander - A person having origins in any of the other original peoples of Hawaii, Guam or Mariana Islands, Samoa, or other Pacific Islands. If Native Hawaiian/Pacific Islander, select the specific sub-category (or sub-categories). Select all that apply from the list provided.
            • Native Hawaiian
            • Guamanian or Chamorro
            • Samoan
            • Other Pacific Islander: The patient identified as some other Native Hawaiian/Pacific Islander subcategory not provided in the options above or did not identify a subcategory.
        • White – Patients race is White or a person having origins in in any of the original peoples of Europe, Middle East or North Africa (e.g., Caucasian, Iranian, White)
        • UTD (Unable to determine) –Unable to determine the patient’s race or not stated (e.g., not documented, conflicting documentation or patient unwilling to provide). The data element Hispanic Ethnicity is required in addition to this Race data element.

        Notes for Abstraction:

        • The data element, Hispanic Ethnicity, is required in addition to this data element.
        • Although the terms "Hispanic" and "Latino" are actually descriptions of the patient's ethnicity, it is not uncommon to find them referenced as race. If the patient's race is documented only as Hispanic/Latino, select "White". If the race is documented as mixed Hispanic/Latino with another race, use whatever race is given (e.g., Black-Hispanic - select "Black"). Other terms for Hispanic/Latino include Chicano, Cuban, H (for Hispanic), Latin American, Latina, Mexican, Mexican-American, Puerto Rican, South or Central American, and Spanish.
        • If the Asian or Native Hawaiian/Pacific Islander patient does not identify a subcategory, leave the sub-category blank.
        Admission Data

      Medical History

      REQUIRED: Previously known medical hx (history) of: (Check all that apply)

      Collected For: All Records

      Definition: Select these elements if the conditions are known to exist prior to admission for the acute (index) event.

      Question: Identify from the following list what the patient's past medical history includes:

      Format: Multi-Select

      Allowable Values:

      • None
      • Atrial Fib/Flutter
      • CAD/prior MI
      • Carotid Stenosis
      • Current Pregnancy (or 6 weeks post-partum)
      • Dementia
      • Depression
      • Diabetes Mellitus
      • Drugs/Alcohol Abuse
      • DVT/PE
      • Dyslipidemia
      • E-Cigarette Use (Vaping)
      • Familial hypercholesterolemia
      • Family History of Stroke
      • HF
      • HRT (Hormone Replacement Therapy)
      • Hypertension
      • Hx of Emerging Infectious Disease
      • Migraine
      • Obesity/Overweight
      • Previous Stroke
      • Previous TIA
      • PVD
      • Prosthetic Heart Valve
      • Renal insufficiency - chronic (Serum Creatinine > 2.0)
      • Sickle Cell
      • Sleep Apnea
      • Smoker

      Notes for Abstraction:

      • Do not include elements that were newly diagnosed during hospitalization and were not previously part of medical history. Therefore, in a case of a patient with newly-diagnosed carotid stenosis, do not select carotid stenosis in the medical history even if it is clear that the stenosis existed prior to the hospitalization.
      • Atrial Fib/Flutter: The patient has ANY prior history of atrial fibrillation OR atrial flutter (i.e., remote, paroxysmal or persistent.) Do not record a history of Atrial Fib/Flutter if the episode was transient AND entirely reversible due to thyrotoxicosis or within 8 weeks of CABG (these are the only two circumstances in which you would not record a history of Atrial fib/flutter). Any patient with a history of Atrial Fib/Flutter who has undergone a procedure for atrial fib/flutter such as pacemaker placement or ablation or who is under medical therapy for rhythm control is still considered as having a history of Atrial Fib/Flutter and you should select afib/flutter under medical history. Example: Documented history of ablation procedure, select Atrial Fib/Flutter here.
      • CAD/prior MI: Select CAD/Prior MI if there is a history of coronary artery disease, or a physician diagnosed MI or EKG evidence of an old MI prior to this event.
      • Carotid Stenosis: Stenosis may be documented either (1) in words in the record as "moderate" or greater than or equal to 50%, (2) previous duplex ultrasound or MR/CT/conventional angiography methods recorded as "moderate" or greater than or equal to 50%, (3) history of carotid endarterectomy or stenting.
      • Dementia: Select Dementia if there is history of dementia documented in the medical record.
      • Depression: Patient has a history of treated depression or is currently taking antidepressant medications for treatment of depression.
      • Diabetes Mellitus (DM): Select if there is a history of physician diagnosed, Diabetes Mellitus (type I or II), regardless of duration of disease or use of treatment including the use of diet, need for antidiabetic agents, oral hypoglycemic agents or insulin, or a fasting blood sugar. Do not include diabetes based on a patient's statement of or based on a single value of elevated blood sugar in the chart. In order to select this element, there must be a confirmed diagnosis of diabetes mellitus. Diabetes is a CHD risk equivalent and associated with worse outcomes.
        • Diabetes Type:
          • Type I Diabetes - A chronic condition characterized by minimal or absent production of insulin by the pancreas.
          • Type II Diabetes - A type of diabetes mellitus that is characterized by insulin resistance or desensitization and increased blood glucose levels. This is a chronic disease that can develop gradually over the life of a patient and can be linked to both environmental factors and heredity.
          • ND - Select ND when there is a documented history of Diabetes Mellitus but the type is not documented.
        • Diabetes Duration: Indicate the estimated duration of diabetes diagnosis (Type I or II), if documented. If not documented, select unknown. If duration is documented as an estimated range (ie: 4 to 5 years) then select the longer duration (ie. 5-<10 years).
      • Drugs/Alcohol Abuse: History of drug and/or alcohol abuse.
      • DVT/PE: Documented history of DVT (Deep Vein Thrombosis) or PE (Pulmonary Embolism). Deep vein thrombosis (DVT) is a clot in a deep vein, unusually in the leg. DVT sometimes affects the arm or other veins. Pulmonary embolism (PE), which occurs when a DVT clot breaks free from a vein wall, travels to the lungs and then blocks some or all of the blood supply.
      • Dyslipidemia: Documented history of Dyslipidemia, if high cholesterol, hyperlipidemia or hypercholesterolemia is present based on physician diagnosis, treatment with a lipid lowering agent, total cholesterol greater than 200, LDL greater than 100, HDL less than 40, or elevated triglycerides greater than 200. Patients on lipid lowering therapy are included in this category even if their LDL levels are in range. See Adult Treatment Protocol (ATP) III Clinical Guidelines for further clarification and methods of calculating goal based on Framingham risk data (www.nhlbi.nih.gov).
      • E-Cigarette Use (Vaping): Use of electronic nicotine delivery system or electronic cigarettes (e-cigarettes), which are battery-operated devices that heat a liquid containing nicotine, propylene glycol, and/or vegetable glycerin and flavorant chemicals to generate an aerosol that the user inhales, or heat-not-burn tobacco products, which are tobacco products that heat to a lower temperature than required for combustion.
        • Reference: Dehmer GJ, Badhwar V, Bermudez EA, Cleveland JC Jr, Cohen MG, D'Agostino RS, Ferguson TB Jr, Hendel RC, Isler ML, Jacobs JP, Jneid H, Katz AS, Maddox TM, Shahian DM. 2020 AHA/ACC key data elements and definitions for coronary revascularization: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Clinical Data Standards for Coronary Revascularization). Circ Cardiovasc Qual Outcomes. 2020;13:e000059. doi: 10.1161/HCQ.0000000000000059
      • Familial hypercholesterolemia: Documented history of Familial hypercholesterolemia (FH).
      • Family History of Stroke: Includes stroke diagnosis in any first degree relative (father, mother, siblings).
      • Heart Failure: Documented history of Heart Failure, includes CHF
      • HRT (Hormone Replacement Therapy): Therapy consisting of estrogen or a combination of estrogen and progestin designed to replace the loss of these hormones in menopause or from oophorectomy. May be also documented as: hormone therapy (HT), estrogen therapy (ET), estrogen replacement therapy (ERT), menopause hormone therapy (MHT).
      • Hypertension: Hypertension (HTN) is present if the patient has a history of high blood pressure whether or not the patient is on prescribed medications, current use of antihypertensive pharmacological therapy or history of HTN diagnosed and treated with medication, diet, and/or exercise. Do not base this decision solely on blood pressure recordings taken in the ED or in the first few days of admission after stroke, since many normotensive patients will have elevated BP after stroke.
      • Hx of Emerging Infectious Disease: Select Hx of Emerging Infectious Disease when the patient is known to have any of the following in their medical history. This does NOT include a current infection:
        • SARS-COV-1 (Severe Acute Respiratory Syndrome-associated coronavirus)
        • SARS-COV-2 (COVID-19) (Severe Acute Respiratory Syndrome-associated coronavirus)
        • MERS (Middle East Respiratory Syndrome)
        • Other Infectious Respiratory Pathogen
      • Migraine: A documented history of migraine headache or of any recurrent or incapacitating headache.
      • Obesity/Overweight: History of obesity/overweight or a BMI of 25 or higher.
      • Previous Stroke: Refers to a history of stroke. If receiving a patient in transfer (i.e. your facility receives drip and ship patients) and there is no history of stroke prior to the acute event for which the patient is being hospitalized, do not select previous stroke.
      • Previous TIA: Refers to a history of transient ischemic attack. If receiving a patient in transfer and there is no history of TIA prior to the acute event for which the patient is being hospitalized, do not select previous TIA.
      • Pregnancy: Includes women who are currently pregnant, or within six weeks post-partum
      • PVD: Peripheral Vascular Disease, refers to a history of peripheral vascular disease of the arteries of the extremities, especially conditions that interfere with adequate blood flow to the extremities and occurring prior to this acute event. Example: peripheral arterial occlusion, abdominal aortic aneurysm.
      • Renal insufficiency – chronic (SCr>2.0): Select if there is a history of physician diagnosed renal insufficiency or chronic failure or if the serum creatinine is greater than 2.0mg/dl.
      • Sickle Cell: Documented history of Sickle Cell. Include Sickle cell disease or sickle cell trait, or sickle cell anemia
      • Sleep Apnea: Patient has a history of sleep apnea, obstructive sleep apnea (OSA), or central sleep apnea (CSA).
      • Smoker: Smoking history - patient has smoked at least one cigarette within the past year.

      When not to select Smoker:

      * In some cases smoking history documentation in one medical record source may further clarify the patient's smoking history documented in another medical record source.
      Examples:

      • Progress note states “history of smoking” and the nursing admission assessment notes “quit 2 years ago” – Do not select Smoker.
      • Discharge summary states smoker without specifying the type of tobacco and the ED record specifies the type of tobacco as cigar – Do not select Smoker.

      * In cases where at least one source has specific documentation that the patient has not smoked anytime during the year prior to hospital arrival - Do not select Smoker.
      Examples:

      • “Current smoker” per H&P, but consultation note states patient “quit 2 years ago” – Do not select Smoker.
      • “ + tobacco use” per ED note, “Smoker – Yes” per nursing admission note, but H&P states, “Quit smoking in 2002” – Do not select Smoker.
      • Progress note states “Still smokes occasionally” but nursing admission assessment has “No” circled next to “Tobacco use within past year” – Do not select Smoker.

      * Do not include documentation of smoking history referenced as a “risk factor” (e.g., “risk factor: tobacco,” “risk factor: smoking,” “risk factor: smoker”), where current smoking status is indeterminable.

      * If there is a history of smoking and documentation indicates the patient quit, but the timeframe in which the patient quit is not clear, Do not select Smoker.
      Examples:

      • Nursing admission assessment documents patient as “ex- smoker” or “former smoker,” or simply notes pt. “quit smoking” - Do not select Smoker.
      • “History of tobacco abuse” per H&P, and consultation note states “nonsmoker” - Do not select Smoker (not a case of conflicting information)

      * Further Examples for not selecting Smoker:

      • Chewing tobacco use only
      • Cigar smoking only
      • Cigarette smoking within one year prior to arrival or any of the other inclusion terms described using one of the following qualifiers: cannot exclude, cannot rule out, may have, may have had, may indicate, possible, suggestive of, suspect or suspicious
      • Illegal drug use only (e.g., marijuana)
      • Oral tobacco use only
      • Pipe smoking only
      • Remote smoker (smoked in the past, but greater than one year ago)

      * E-cigarettes and vapors are not considered smoking. Please select smoker = No if these are the only products being used by the patient.

      When to select Smoker:

      * In cases where conflicting information about the patient's smoking history is documented and there is no specific documentation that the patient has not smoked during the year prior to hospital arrival, select Smoker.
      Examples:

      • "Current smoker” per H&P, but ED note states “Non-smoker” – select Smoker.
      • “Cigarette Smoking: Yes, 1-2 cigarettes a day” on nursing admission
      • “Cigarette Smoking: Yes, 1-2 cigarettes a day” on nursing admission note, but “Smoking – Quit” on H&P – select Smoker.
      • “Recent smoker” in H&P, but progress note states “Smokes – No” – select Smoker.

      * If there is documentation of current smoking or tobacco use, or a history of smoking or tobacco use, and the type of product is not specified, assume this refers to cigarette smoking.

      * If there is a history of smoking and documentation that the patient quit “several months ago,” infer the patient smoked within one year prior to arrival, and select Smoker.

      * Further Examples for selecting Smoker:

      • + smoker, type of product not identified
      • + tobacco use, type of product not identified
      • History of cigarette use without mention of a time frame, if no indication that patient quit
      • History of smoking (type of product not identified), without mention of a time frame, if no indication that patient quit
      • History of smoking and documentation that the patient quit “several months ago”
      • History of smoking within one year prior to arrival, type of product not identified
      • History of tobacco use (type of product not identified), without mention of a time frame, if no indication that patient quit
      • History of tobacco use within one year
      • Indication that patient quit
      • History of smoking and documentation that the patient quit “several months ago”
      • History of smoking within one year prior to arrival, type of product not identified
      • History of tobacco use (type of product not identified), without mention of a time frame, if no indication that patient quit
      • History of tobacco use within one year prior to arrival, type of product not identified
      • Recent smoker

      Suggested Data Sources:

      • Admission Data
      GWTG® – Stroke, HF, CAD Guidelines for Abstraction to determine when to select Medical History = Smoker
      Inclusion Exclusion
      Cigarette smoker, type of product not identified Use of only chewing tobacco
      Tobacco user, type of product not identified Use of only cigar or pipe smoking
      History of smoking and documentation that the patient quit &several months ago" or "recent smoker" Use of only oral tobacco
      History of smoking or use of tobacco within one year prior to arrival, type of product not identified Use of only illegal drugs use (e.g., marijuana)
      History of cigarette use without mention of time frame, if no indication that patient quit Remote Smoker (previous use was greater than one year)

      Summary of Changes

      REQUIRED FOR COVERDELL ONLY: Ambulatory status prior to the current event? (What was patient's ambulatory status prior to the current event?)

      Indicate the patient's ambulatory status prior to the current event.

      For patients who are in a healthcare environment prior to admission:

      • Patient ambulating without assistance (no help from another person) with or without a device. This means patient is able to ambulate without help from another person. The use of a device, such as a cane, still meets this definition. Patient ambulating to and from the bathroom unassisted. Even though actual ambulation is not documented in the medical record, privileges to walk to and from the bathroom and evidence of the patient getting out of bed unassisted are considered to meet the definition of ambulation.
      • Patient ambulating with assistance of another person.
      • : Patient is on bedrest. Patient is only getting out of bed to the bedside commode (or up in chair) and is primarily in the bed (or immobile).
      • If it is unable to determine from documentation.

      For patients not in a healthcare setting prior to admission:

      • Able to ambulate independently (no help from another person) w/ or w/o device: Patient ambulating without assistance (no help from another person) with or without a device. This means patient is able to ambulate without help from another person. The use of a device, such as a cane, still meets this definition. Patient ambulating around the house unassisted, even if they need assistance to walk outside.
      • With assistance (from person): Patient ambulating with assistance of another person.
      • Unable to ambulate: Patient is bedridden or currently on bedrest recovering from an injury or illness. Patient is only getting out of bed to the bedside commode (or up in chair) and is primarily in the bed (or immobile)
      • ND: If it is unable to determine from documentation.

      Examples:

      • Patient 055a walks around the home but rides a motorized scooter when outdoors. Select "Able to ambulate independently (no help from another person) w/ or w/o device".
      • Patient 055b has severe arthritis and is sedentary throughout most of the day, they require a full person assistance to transfer from bed to chair. Select "Unable to ambulate."

      Admission Data, especially Physical or Occupational therapy consultation or progress notes

      Summary of Changes


      Pre-stroke Modified Rankin Score

      Collected For: CSTK

      Definition: The pre-stroke Modified Rankin Score (mRS) is a score used to assess the patient's pre-stroke or baseline level of function. Scores reflect the patient's ability to perform activities of daily living prior to the hospitalization for the acute ischemic stroke event.

      Score Description
      0 The patient had no residual symptoms
      1 The patient had no significant disability; able to carry out all activities
      2 The patient has slight disability; unable to carry out all pre-stroke activities but able to look after self without daily help
      3 The patient has moderate disability; requiring some external help but able to walk without the assistance of another individual
      4 The patient has moderately severe disability; unable to walk or attend to bodily functions without assistance of another individual
      5 The patient has severe disability; bedridden, incontinent, requires continuous care

      Question: What is the patient's pre-Stroke Modified Rankin Score (mRS)?

      Format: Drop Down

      Allowable Values:

      • 1 - A pre-stroke mRS of 0, 1, or 2 was documented in the medical record, OR physician/APN/PA documentation that the patient was able to look after self without daily help prior to this acute stroke episode.
      • 2 - A pre-stroke mRS of 3, 4, or 5 was documented in the medical record, OR physician/ APN/ PA documentation that the patient could NOT look after self without daily help prior to this acute stroke episode.
      • 3 - A pre-stroke mRS was not documented, OR unable to determine (UTD) from the medical record documentation.

      Notes for Abstraction:

      • A pre-stroke mRS value (i.e., 0, 1, 2, 3, 4, or 5) may be documented by the physician/APN/PA, nurse (RN), medical assistant, or any individual trained to perform the mRS.
      • If more than one pre-stroke mRS value is documented, select the highest value.
      • If a score range is documented, e.g. 2-3, select the higher value.
      • Pre-stroke mRS values may be documented any time during the hospital stay or within 30 days prior to hospital arrival.
      • EXCEPTION:
        • A discharge mRS cannot be used as a baseline pre-stroke mRS score. Score documentation must clearly reflect the patient's functional status prior to arrival at the hospital for management of the acute ischemic stroke event.
      • If an acutal pre-stroke mRS value is not documented in the medical record, physician/APN/PA documentation only may be used to document the patient's pre-stroke functional status. EXAMPLES:
        • "Patient independent and living alone prior to stroke onset. No past history of TIA or stroke", select allowable value "1".
        • "Mrs. X lives with her daughter and has some memory deficit requiring assistance with meals and dressing. Ambulates without help", select allowable value "2".
      • If there is conflicting documentation of baseline pre-stroke functional status in the medical record, select the highest score value.
      • If there is an actual pre-stroke mRS value documented in the medical record, then that score should be used for abstraction over other physician/APN/PA documentation.
      • If no pre-stroke mRS is documented or unable to determine, select allowable value "3".

      Suggested Data Sources:

      • Consultation Notes
      • Emergency Department Record
      • History and Physical
      • Progress Notes
      • Discharge Summary
      • Admission Note
      • Outpatient Record

      Additional Notes / Guidelines for Abstraction Inclusion:

      • Excluded Data Sources:
        • Any documentation dated/ timed after discharge

      Exclusion:

      • None

      Summary of Changes


      Diagnosis and Evaluation

      OPTIONAL: Symptom Duration if diagnosis of Transient Ischemic Attack (<24 hours)

      Document symptom duration if diagnosis of Transient Ischemic Attack (< 24 hours)

      • Less than 10 minutes
      • 10 – 59 minutes
      • ≥ 60 minutes
      • ND

      Estimate the time of symptom duration for patients with transient neurological symptoms that are felt to be due to cerebral ischemia. When a range of time duration is provided in the record, choose the upper most limit. For example, if it states, “symptoms lasted between 5-20 mins”, then select "10 - 59 minutes" since 20 minutes would fall into the “10-59 min” range.

      Example: Patient 070a experiences weakness of the face, arm and leg, and has difficulty speaking (dysarthria) lasting for less than 5 minutes. Select "Less than 10 minutes"

      Admission Data

      Summary of Changes

      REQUIRED FOR COVERDELL ONLY: Had stroke symptoms resolved at time of presentation?

      Indicate if symptoms already resolved upon hospital arrival.

      • Yes
      • No
      • ND

      Notes for Abstraction:

      • For inpatient stroke, select "No" since time of presentation (for stroke) = time of symptom discovery.
      Admission Data

      Summary of Changes

      REQUIRED: Initial NIH Stroke scale

      Was NIH Stroke Scale (NIHSS) performed as part of initial evaluation?

      • Yes: An NIH Stroke Scale was performed as part of the initial evaluation or neurology consultation.
      • No/ND: An NIH Stroke Scale was not performed or was performed but the total score is not available.

      Notes for Abstraction:

      • You should be looking for the first NIHSS calculated or documented based on the first arrival notes or in the first neurology consultation note, whichever comes first. Patients with acute ischemic stroke treated with intravenous alteplase or with an acute endovascular procedure at your facility should be included as a “Yes” response only if the NIHSS is performed before the start of these treatments. If the first NIH Stroke Scale score was calculated or documented only after treatment with intravenous tPA or acute endovascular procedure at your facility, 48 hours after arrival in those patients that do not receive thrombolytic treatment, or not performed at all, then select "No/ND."
      • If comprehensive neurological findings are outlined in first arrival notes or in the first neurology consultation note that enables you to abstract the complete NIHSS, answer "Yes" to this data element and enter the findings into the sub questions under the “Total Score”.
      • If another stroke scale was performed instead, including the Modified NIH Stroke Scale, answer “No/ND”.
      • For patients that receive thrombolytic therapy at an outside hospital prior to transfer to your facility, answer this data element based off of the first NIHSS performed at your own hospital. For patients received in transfer that undergo additional treatment such as IA catheter based reperfusion or mechanical recanalization at your facility, answer “Yes” only in those patients in whom an NIHSS is performed prior to this treatment. For patients received in transfer that do not undergo additional treatment, answer “Yes” only if the first NIHSS was performed at your facility within 48 hours of arrival.
      • The initial NIH Stroke Scale may be documented by a member of the "stroke team" (including the physician/APN/PA or nurse (RN)). It is highly recommended that the NIHSS be performed by a certified examiner.
      • For inpatient stroke, you should be looking for the first NIHSS calculated or documented in the first neurology consultation note, or medical encounter note, after discovery of stroke symptoms in the hospital. Patients with an inpatient acute ischemic stroke treated with intravenous alteplase, or with an acute endovascular procedure, should be included as a “Yes” response only if the NIHSS is performed before the start of these treatments. If the patient arrives to the hospital with transient symptoms that resolve, and an NIHSS was performed at that time, but later in the hospital stay the patient has new onset stroke symptoms and meets criteria to be entered as an inpatient stroke, a new NIHSS should be performed and the results of the NIHSS performed after discovery of new onset of stroke symptoms should be used. If a new NIHSS is not performed after new symptom discovery, select "No/ND". Do not use the results of the NIHSS done prior to new symptom discovery.
      • Example: Patient 072 presents to the ED with complaints of dizziness, fatigue, and slurred speech which resolve prior to admission. NIHSS was documented as 1. The following day, the patient has new onset slurred speech and right leg weakness. NIHSS is performed immediately after stroke symptom discovery and is documented as a 6. Enter this patient as an inpatient stroke and select "Yes" for "Initial NIH Stroke scale" and enter 6 for "Total Score".
      Admission Data

      Summary of Changes

      OPTIONAL: If Yes (NIHSS)

      If NIHSS score present in eCRF (PMT) what method was used to obtain the NIHSS score recorded.

      • Actual: NIHSS score was documented in the record as the result of the scale being performed
      • Estimated from the record: NIHSS score was reconstructed retrospectively based on neurological exam findings
      • ND: The method of NIHSS score calculation was not documented

      Admission Data

      Summary of Changes

      REQUIRED: Total Score

      If Initial NIH stroke scale was performed, what is the first NIH Stroke Scale total score recorded by hospital personnel. Click on (Show/Hide) to display the sub-questions from the NIH Stroke Scale. The total will be computed automatically from these sub-questions. Completing the NIHSS sub-questions is optional.

      Notes for Abstraction:

      • Enter the total score of the first NIHSS performed prior to treatment with thrombolytic therapy or acute endovascular procedure at your hospital within 48 hours of hospital arrival for those patients that did not undergo treatment with thrombolytics or an acute endovascular procedure.
      • The initial NIH Stroke Scale may be documented by a member of the "stroke team" (including the physician/APN/PA or nurse (RN)).  It is highly recommended that the NIHSS be performed by a certified examiner.

      Admission Data

      Summary of Changes

      Initial NIHSS <6

      Collected For: CSTK

      Definition: Documentation that the initial National Institutes of Health Stroke Scale (NIHSS) score after hospital arrival was less than 6.

      Question: Was the initial NIHSS score after hospital arrival less than 6?

      Format: Single Select

      Allowable Values:

      • Y (Yes) The initial NIHSS score after hospital arrival was less than 6.
      • N (No) The initial NIHSS score after hospital arrival was 6 or greater, OR unable to determine from the medical record documentation.

      Notes for Abstraction:

      • Select the first total NIHSS score (i.e., sum of the category scores) documented after hospital arrival.
      • The NIHSS score may be documented by the physician/APN/PA or nurse (RN).
      • Disregard components scored when the total NIHSS score is not documented or left blank. Do not infer a total NIHSS score from documented category scores.

      Suggested Data Sources/b>:

      • Consultation notes
      • Emergency department record
      • History and physical
      • Nursing flow sheet
      • Nursing admission assessment
      • Progress notes
      • Admitting note

      Additional Notes / Guidelines for Abstraction:

      • Inclusion: None
      • Exclusion:
        • Modified NIHSS scores
        • Estimated NIHSS scores
        • Scoring methodologies other than NIHSS

      Summary of Changes

      REQUIRED FOR COMPREHENSIVE: What is the first NIHSS score obtained prior to or after hospital arrival?

      Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

      Data Element Name: Initial NIHSS Score at Hospital Arrival

      Collected For: CSTK-05, CSTK-08

      Definition: Documentation of the first NIHSS score obtained prior to or after hospital arrival. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language.

      Suggested Data Collection Question: What is the first NIHSS score obtained prior to or after hospital arrival?

      Format

      Length:
      3 (0 to 42)
      Type: Alphanumeric
      Occurs:1

      Allowable Values:
      Score = XX (0-42)
      UTD = Unable to Determine

      Notes for Abstraction:

      • To determine the value for this data element, review the NIHSS scores obtained prior to and after hospital arrival.
      • Select the earliest documented NIHSS score regardless of where it was done. Values obtained and documented by EMS, teleneurology, a transferring hospital, or your hospital are acceptable. The first documented NIHSS score should be used.

      Suggested Data Sources:

      • Emergency department record
      • History and physical
      • Nursing flow sheet
      • Progress notes
      • Transfer sheet
      • Admitting note
      • Ambulance record
      • Consultation form/note
      • Nursing assessment
      • EMS records

      Excluded Data Sources:

      • Discharge summary

      Guidelines for Abstraction

      Inclusion: None

      Exclusion:

      • Modified NIHSS scores
      • Estimated NIHSS scores
      • Scoring methodologies other than NIHSS

      Summary of Changes

      REQUIRED FOR COMPREHENSIVE: Is there documentation that an initial NIHSS score was done at this hospital?

      Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

      Data Element Name: Initial NIHSS Score Performed

      Collected For: CSTK-01

      Definition: Documentation of the first National Instititutes of Health Stroke Scale (NIHSS) score that was done at this hospital. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language. The NIHSS serves several purposes, but its main use in clinical medicine is during the assessment of whether or not the degree of disability caused by a given stroke merits treatment with alteplase. Score documentation may range from 0 to 42.

      Suggested Data Collection Question: Is there documentation that an initial NIHSS score was done at this hospital?

      Format

      Length:
      1
      Type: Alphanumeric
      Occurs: 1

      Allowable Values:

      Y (YES) Initial NIHSS score was done at this hospital.

      N (No) Initial NIHSS score was not done at this hospital, OR Unable to determine (UTD) from the medical record documentation.

      Notes for Abstraction:

      • The NIHSS score may be documented by the physician/APN/PA or nurse (RN).
      • If a total NIHSS score (i.e., sum of the category scores) is documented, select 'YES'.
      • Total scores obtained by teleneurology and documented in the medical record, select 'YES'.
      • If components are scored but the total NIHSS score is not documented or left blank, select 'NO'. Do not infer a total NIHSS score from documented category scores.

      Suggested Data Sources:

      • Consultation notes
      • Emergency department record
      • History and physical
      • Nursing flow sheet
      • Progress notes
      • Admitting note
      • Nursing assessment

      Guidelines for Abstraction

      Inclusion: None

      Exclusion:

      • Modified NIHSS scores
      • Estimated NIHSS scores
      • Scoring methodologies other than NIHSS

      Summary of Changes

      REQUIRED FOR COMPREHENSIVE: What is the date and time that the NIHSS score was first performed at this hospital?

      Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

      Data Element Name: Initial NIHSS Score Date/Time

      Collected For: CSTK-01

      Definition: The month, date, year, and time (military time) that the NIHSS score was first performed at this hospital. The NIH stroke scale measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language. The NIH stroke scale serves several purposes, but its main use in clinical medicine is during the assessment of whether or not the degree of disability caused by a given stroke merits treatment with alteplase.

      Suggested Data Collection Question: What is the date and time that the NIHSS score was first performed at this hospital?

      Format

      Length:
      10 - MM-DD-YYYY (includes dashes) or UTD, 5 - HH-MM (with or without colon) or UTD
      Type: Date/Time
      Occurs: 1

      Allowable Values:

      MM = Month (01-12)
      DD = Day (01-31)
      YYYY = Year (2001-Current Year)
      UTD = Unable to Determine

      HH = Hour (00-23)
      MM = Minutes (00-59)
      UTD = Unable to Determine

      Notes for Abstraction:

      • Use the date that the NIHSS score was first performed. If a discrepancy exists in date documentation from different sources, choose the earliest date. If there are two or more initial NIHSS score dates (either different NIHSS assessments or corresponding with the sameassessment), enter the earliest date.
      • If the initial NIHSS score date is unable to be determined from medical record documentation, select UTD.
      • The medical record must be abstracted as documented (taken at face value). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD.
        Example:
        Documentation indicates the initial NIHSS date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the initial NIHSS date is outside of the range listed in the Allowable Values for Day, it is not a valid date and the abstractor should select UTD.
        Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commissions Data Warehouse. Use of UTD for Initial NIHSS Score Date allows the case to be accepted into the warehouse.
      • Use the time for which the NIHSS score was first performed. If a discrepancy exists in time documentation from different sources, choose the earliest time. If there are two or more different initial NIHSS score times (either different NIHSS assessments or corresponding with the sameassessment), enter the earliest time.
      • If the time of the first NIHSS score is a time prior to hospital arrival because the score was obtained by teleneurology or MD/APN/PA directly receiving the patient via life flight, use the Arrival Time for the score time.
      • For times that include seconds, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00
      • Initial NIHSS Score Time refers to the time that the first NIHSS score was performed. If the time performed is mentioned in the body of a note, select the time performed rather than the time stamp on the note. If the only time documented with the score is the time stamp on the note, then select the time stamped. Examples:
        • Documentation indicates that the initial NIHSS score was done at 0920. Time stamp on the note is 1159. The abstractor should select 0920 for Initial NIHSS Score Time.
        • Documentation indicates that the NIHSS score done on arrival was 12. Patient arrived at your hospital 2100. Time stamp on the note is 2136. The abstractor should select 2100 for Initial NIHSS Score Time.
        • NIHSS score 12 [no time] documented. Time stamp on the note is 1513. The abstractor should select 1513 for Initial NIHSS Score Time.
      • Do not use physician orders as they do not demonstrate the NIHSS score was done (in the ED this may be used if signed/initialed by a nurse).
      • Times for scores done prior to arrival by a teleneurologist are acceptable if signed/initialed by a nurse.
      • If the time of the first NIHSS score is unable to be determined from medical record documentation, select UTD.
      • The medical record must be abstracted as documented (taken at face value). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select UTD.
        Example:
        Documentation indicates the initial NIHSS score time was 3300. No other documentation in the medical record provides a valid time. Since the initial NIHSS score time is outside of the range listed in the Allowable Values for Hour, it is not a valid time and the abstractor should select UTD.
        Note: Transmission of a case with an invalid time as described above will be rejected from the Joint Commissions Data Warehouse. Use of UTD for Initial NIHSS Score Time allows the case to be accepted into the warehouse.

      Suggested Data Sources:

      • Consultation notes
      • Emergency department record
      • History and physical
      • Nursing flow sheet
      • Progress notes
      • Admitting note
      • Nursing assessment

      Guidelines for Abstraction

      Inclusion: None

      Exclusion: None

      Summary of Changes

      OPTIONAL: NIHSS Score Obtained from Transferring Facility

      If the patient arrived to your hospital as a transfer from another hospital, enter the total NIHSS obtained from the transferring facility prior to patient transfer.

      Notes for Abstraction:

      • If more than one NIHSS is performed at the transferring facility, enter the first score recorded. 
      • If NIHSS from transferring facility is not available, leave blank.
      • The NIHSS performed at the transferring hospital is not a substitute for performing the NIHSS at your hospital. It is expected that the NIHSS be performed by an appropriate clinician at your hospital and you must complete the data elements of “Initial NIH Stroke Scale” and “Total Score” based upon care provided at your hospital. The “NIHSS Score Obtained from Transferring Facility” does not qualify in the measure “NIHSS Reported” at your hospital.

      Summary of Changes

      REQUIRED: Initial Exam Findings

      This data element is only required if Initial NIH Stroke Scale = No (meaning that an initial NIHSS was not performed or was performed but the total score is not available). If Initial NIH Stroke Scale = Yes then this data element (Initial Exam Findings) is Optional (and is not necessary to save the record as complete.)

      Identify from the initial (first) neurological exam in the record which of the following findings were present at the time of hospital arrival or when the first complete exam was performed on the patient. Select all that apply:

      • Weakness/Paresis: Includes any mention of weakness or paresis of an arm, leg, side of the face, or any part of the body. This includes documentation of terms such as hemiparesis, hemiplegia, quadriparesis, quadriplegia, paraparesis, or paraplegia, as well as flaccidity or drift of the limbs, facial droop, or evidence of impaired strength. This element does NOT include mention of clumsiness, ataxia, incoordination, gait trouble, fatigue or generalized weakness.
      • Altered Level of Consciousness: Includes any mention of decreased alertness, sleepiness, drowsiness, stupor, coma, difficulty to arouse, need for painful stimulation to gain the patients attention, Documentation of a Glasgow Coma Score (GCS) that includes No eye opening. Eye opening to pain or Eye opening to verbal command would qualify.
      • Aphasia/Language Disturbance: Includes loss of the ability to communicate or disturbances of language and communication. This can be documented as slurring of speech, dysarthria, difficulty with producing speech (including the terms non-fluent, Broca’s, Wernike’s, paraphasia, dysphasia, mutism), following commands, naming objects, repeating phrases, speaking fluently, or answering questions appropriately. Documentation of a Glasgow Coma Score (GCS) that includes No verbal response, Incomprehensible sounds or Inappropriate words would qualify.
      • Other neurological signs/symptoms: Other neurological findings were documented in the record which do not fit the above specified categories.
      • No neurological signs/symptoms: No neurological signs or symptoms were present on arrival or when the first neurological exam was performed. If you select this option, you should not check any other box.
      • ND: There is no documentation of neurological signs and symptoms in the record because there was no neurological exam performed at any at any point in the hospital stay. If you select this option, you should not check any other box.

      Notes for Abstraction:

      • The initial exam findings should be determined based upon the first neurological exam performed on the patient whether performed on arrival, in the ED or later in the hospital stay and should be documented by a physician (including an ED physician or neurologist).
      • If the patient’s neurological exam is limited due to loss of consciousness or other conditions select only those findings that have been assessed. Do not infer the presence of findings. Record only those findings found in the hospital record.
      • Only select “ND” if there was no neurological exam performed during the hospital stay. Do NOT select "ND" based solely on whether an exam is documented in the ED notes. If an initial neurological exam was not performed in the ED, use the first documented exam during the hospital stay and record the findings of that exam. There is no time limit on when the exam should have been performed. Use the first exam, even if it occurs later in the hospital stay after ED admission.
      • If the NIHSS or Glasgow Coma Scale is performed as a component of the initial (first) neurological exam, it is acceptable to use the individual components of the NIHSS or Glasgow Coma Scale, if documented in the medical record to assist in identifying the presence of the following signs or symptoms.
      • Use only information obtained once the patient has arrived at the hospital (i.e. if the only documented GCS is from EMS records prior to patient arrival to your ED, you should not use this documentation).
      • For inpatient stroke, use the first neurological exam performed after the date/time of discovery of stroke symptoms in the hospital. If the patient arrives to the hospital with transient symptoms that resolve and a neurological exam was performed but later in the hospital stay the patient has new onset stroke symptoms and meets criteria to be entered as an inpatient stroke, a new neurological exam should be performed and the results from the new exam should be used to select initial exam findings.

      Note: The presence of weakness, altered level of consciousness or aphasia/language disturbance has been shown to be correlated with worse patient outcomes.

      Example: Patient 071 presents with visual loss, right body tingling, and ataxia documented on the admission notes. Weakness, altered level of consciousness, and aphasia are not present. Select "Other neurological signs/symptoms".

      Patient 071B presents to the ED with complaints of dizziness, fatigue, and slurred speech. Symptoms resolve while in the ED. Patient is admitted and the following day the patient has new onset of slurred speech and right leg weakness and is diagnosed with an ischemic stroke. Enter this patient as an inpatient stroke and select "Aphasia/Language Disturbance" and "Weakness/Paresis".

      Admission Data

      Summary of Changes

      OPTIONAL: Ambulatory status on admission

      Indicate the patient's current ambulatory status in the context of their stroke/TIA symptoms. This should be based on the examination in the ER or within the first 24 hours of admission. For patients that are not permitted to ambulate, answer this data element based on what the patient would be capable of if allowed to ambulate.

        • Able to ambulate independently (no help from another person) w/ or w/o device
        • With assistance (from person)
        • Unable to ambulate
        • ND

        Notes for Abstraction:

        • Able to ambulate independently (no help from another person) w/ or w/o device: Patient ambulating without assistance (no help from another person) with or without a device. This means patient is able to ambulate without help from another person. The use of a device, such as a cane, still meets this definition.
        • With assistance (from person): Patient ambulating with assistance of another person.
        • Unable to ambulate: Patient is unable to ambulate safely.
        • ND: If it is unable to determine from documentation.
        • For inpatient strokes, enter the patients ambulatory status on arrival to the ED or within 24 hours of actual hospital admission. 

      Examples:

      • Patient 100a is evaluated in the ER and is noted to require maximum 2 person assist to stand at the side of the bed and is noted to be unsafe to ambulate without assistance. Select "Unable to ambulate".
      • Patient 100b is noted to have facial weakness and slurred speech, but is able to ambulate independently. Select "Able to ambulate independently".
      • Patient 100c has mild right leg weakness and is unsteady standing independently but is able to walk safely with minimal support of his hand by the nurse. Select "With assistance from another person"
      • Patient 100d is confined to bed rest post-procedure (i.e. femoral artery puncture). The patient is capable of independent ambulation but is not permitted to do so. Select “Able to ambulate independently (no help from another person) w/ or w/o device.”

      Admission Data

      Summary of Changes

      OPTIONAL COMPREHENSIVE: First Glasgow Coma Scale (GCS)

      The Glasgow Coma Scale (GCS) is used to measure severity of intracerebral hemorrhage. It has been shown to be a predictor of outcome from the bleed. The GCS should be collected on all patients who present with an intracerebral hemorrhage.

      Notes for Abstraction:

      • Record the first GCS documented. This can either be the one completed by EMS, or if not completed by EMS then the first one done in the hospital.
      • Record GCS scores for eye, verbal, and motor response. The total score will automatically be generated. If patient has endotracheal tube in place at the time GCS measured, check "intubated" and leave the verbal score blank.
      • If only a total score is documented, only fill in "Total GCS" score and leave the sub-components blank.
      • If the patient has not suffered an intracerebral hemorrhage, this field will be disabled.

      Example: A patient is admitted with a large intracerebral hemorrhage. His eyes open to painful stimuli (2 points), his best motor response is to localize pain to painful stimuli (5 points) and his best verbal response is no response (1 point). His Glasgow Coma Score is 8.

      https://osstatic.irp.iqvia.com/online_doc_qi/StrokePMT/coding_instruction/source.jpgPre-hospital Data, Emergency Department Data, Admission Data

      Summary of Changes

      REQUIRED FOR COMPREHENSIVE: ^Is there documentation any time during the hospital stay that the hemorrhage was non-aneurysmal or due to head trauma?

      Required for TJC CSTK

      Data Element Name:Non-aneurysmal

      Collected For: CSTK-03

      Definition: Patients with documentation of non-aneurysmal SAH or SAH related to head trauma any time during the hospital stay. Non-aneurysmal SAH refers to hemorrhage in the subarachnoid space that is not attributed to the ruptured of a cerebral aneurysm.

      Data Collection Question: Is there documentation any time during the hospital stay that the hemorrhage was non-aneurysmal or due to head trauma?

      Format

      Length:
      1
      Type: Alphanumeric
      Occurs: 1

      Allowable Values:

      Y (YES) There is documentation any time during the hospital stay that the hemorrhage was non-aneurysmal or due to head trauma.

      N (No) There is no documentation any time during the hospital stay that the hemorrhage was non-aneurysmal or due to head trauma, OR unable to determine from the medical record documentation.

      Notes for Abstraction:

      • The timeframe for documentation of this data element is any time during the hospital stay from hospital arrival to discharge.
      • Only accept terms identified in the list of inclusions. No other terminology will be accepted.
      • Terms must be documented by a physician/APN/PA only.

      Suggested Data Sources:

      • Consultation notes
      • Emergency department record
      • >History and physical
      • Progress notes
      • Discharge Summary

      Additional Notes

      Guidelines for Abstraction

      Inclusion:

      • >Head trauma
      • Non-aneurysmal
      • >Not aneurysmal
      • Trauma

      Exclusion:

      • Trauma other than head
      • Trauma or traumatic injuries involving body parts other than the head

      REQUIRED FOR COMPREHENSIVE: Was an initial ICH score done at this hospital?

      Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

      Data Element Name: Initial ICH Score Performed

      Collected For: CSTK-03

      Definition: Documentation of the first ICH score that was done at this hospital. The ICH Score is a clinical grading scale composed of factors related to a basic neurological examination (GCS), a baseline patient characteristic (age), and initial neuroimaging (ICH volume, IVH, infratentorial/supratentorial origin). Score documentation may range from 0 to 6. The purpose of this grading scale is to provide a standard assessment tool that can be easily and rapidly determined at the time of ICH presentation by physicians without special training in stroke neurology and that will allow consistency in communication and treatment selection in clinical care and clinical research.

      Component

      Criteria

      Points

      GCS

      3-4

      2

       

      5-12

      1

       

      13-15

      0

      ICH Volume (cc)

      >/=30cc

      1

       

      <30cc

      0

      Intraventricular Hemorrhage

      Yes

      1

       

      No

      0

      Infratentorial Origin

      Yes

      1

       

      No

      0

      Age

      >/=80 years old

      1

       

      <80 years old

      0

      Total ICH Score

       

      0-6

       

      Suggested Data Collection Question: Was an initial ICH score done at this hospital?

      Format

      Length:
      1
      Type: Alphanumeric
      Occurs: 1

      Allowable Values:

      Y (YES) Initial ICH score was done at this hospital.

      N (No) Initial ICH score was not done at this hospital, OR Unable to determine (UTD) from the medical record documentation.

      Notes for Abstraction:

      • The ICH score may be documented by the physician/APN/PA or nurse (RN).
      • ICH score obtained by teleneurology and documented in the medical record, select 'YES'.
      • If a total ICH score (i.e., sum of the component points) is documented, select ‘YES’.
      • f components are scored but the total ICH score is not documented or left blank, select ‘NO’. Do not infer a total ICH score from documented component scores.
        Do not infer a total ICH score from documented component scores.

      Suggested Data Sources:

      • Consultation notes
      • Emergency department record
      • History and physical
      • Progress notes
      • Admitting note

      Guidelines for Abstraction

      Inclusion: None

      Exclusion:

      • Scoring methodologies other than the ICH Score

      Note: To enable a response, abstractors may first need to answer 'No' for the question Was an initial Hunt and Hess scale done at this Hospital?

      Summary of Changes

      OPTIONAL COMPREHENSIVE: If yes, (ICH) Score

      If an ICH score was performed, enter the first ICH Score total score as recorded by hospital personnel.  Score documentation may range from 0 to 6. 

      Notes for Abstraction:

      • Enter the total score of the first ICH score performed within 24 hours of hospital arrival and prior to the initiation of any invasive intracranial procedure.
      • First ICH score can be recorded by a physician/APN/PA or nurse.

      https://osstatic.irp.iqvia.com/online_doc_qi/StrokePMT/coding_instruction/source.jpgEmergency Department Data, Admission Data

       Summary of Changes

      Summary of Changes

      REQUIRED FOR COMPREHENSIVE: What is the date and time that the ICH score was first performed at this hospital?

      Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

      Data Element Name: Initial ICH Score Date/Time

      Collected For: CSTK-03

      Definition: The month, date, year, and time (military time) that the ICH score was first performed at this hospital. The ICH Score is a clinical grading scale composed of factors related to a basic neurological examination (GCS), a baseline patient characteristic (age), and initial neuroimaging (ICH volume, IVH, infratentorial/supratentorial origin). The purpose of this grading scale is to provide a standard assessment tool that can be easily and rapidly determined at the time of ICH presentation by physicians without special training in stroke neurology and that will allow consistency in communication and treatment selection in clinical care and clinical research.

      Suggested Data Collection Question: What is the date and time that the ICH score was first performed at this hospital?

      Format

      Length:
      10 - MM-DD-YYYY (includes dashes) or UTD, 5 - HH-MM (with or without colon) or UTD
      Type: Date/Time
      Occurs: 1

      Allowable Values:

      MM = Month (01-12)
      DD = Day (01-31)
      YYYY = Year (2001-Current Year)
      UTD = Unable to Determine

      HH = Hour (00-23)
      MM = Minutes (00-59)
      UTD = Unable to Determine

      Notes for Abstraction:

      • Use the date that the ICH score was first performed. If a discrepancy exists in date documentation from different sources, choose the earliest date. If there are two or more initial ICH score dates (either different ICH assessments or corresponding with the same assessment), enter the earliest date.
      • If the initial ICH score date is unable to be determined from medical record documentation, select UTD.
      • The medical record must be abstracted as documented (taken at face value). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD.
        Example:
        Documentation indicates the initial ICH score date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the initial ICH score date is outside of the range listed in the Allowable Values for Day, it is not a valid date and the abstractor should select UTD.
        Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commissions Data Warehouse. Use of UTD for Initial ICH Score Date allows the case to be accepted into the warehouse.
      • Use the time for which the ICH score was first performed. If a discrepancy exists in time documentation from different sources, choose the earliest time. If there are two or more different initial ICH score times (either different ICH assessments or corresponding with the same assessment), enter the earliest time.
      • If the time of the first ICH score is a time prior to hospital arrival because the score was obtained by teleneurology or MD/APN/PA directly receiving the patient via life flight, use the Arrival Time for the score time.
      • For times that include seconds, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00
      • Initial ICH Score Time refers to the time that the first ICH score was performed. If the time performed is mentioned in the body of a note, select the time performed rather than the time stamp on the note. If the only time documented with the score is the time stamp on the note, then select the time stamped. Examples:
        • Documentation indicates that the initial ICH score was done at 0920. Time stamp on the note is 1159. The abstractor should select 0920 for Initial ICH Score Time.
        • Documentation indicates that the ICH score done on arrival was 5. Patient arrived at your hospital 2100. Time stamp on the note is 2136. The abstractor should select 2100 for Initial ICH Score Time.
        • ICH score 5 [no time] documented. Time stamp on the note is 1513. The abstractor should select “1513 for Initial ICH Score Time.
      • Do not use physician orders as they do not demonstrate the ICH score was done (in the ED this may be used if signed/initialed by a nurse).
      • If the time of the first ICH score is unable to be determined from medical record documentation, select UTD.
      • The medical record must be abstracted as documented (taken at face value). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select UTD.
        Example:
        Documentation indicates the initial ICH score time was 3300. No other documentation in the medical record provides a valid time. Since the initial ICH score time is outside of the range listed in the Allowable Values for Hour, it is not a valid time and the abstractor should select UTD.
        Note: Transmission of a case with an invalid time as described above will be rejected from the Joint Commissions Data Warehouse. Use of UTD for Initial ICH Score Time allows the case to be accepted into the warehouse.

      Suggested Data Sources:

      • Consultation notes
      • Emergency department record
      • History and physical
      • Progress notes
      • Admitting note

      Guidelines for Abstraction

      Inclusion: None

      Exclusion: None

      Summary of Changes

      OPTIONAL COMPREHENSIVE: FUNC Score (ICH)

      The FUNC (Functional outcome risk stratification) score assesses the patient for risk of functional impairment post-stroke. Enter a score of 0-11.

      REQUIRED FOR COMPREHENSIVE: Was an initial Hunt and Hess scale done at this hospital?

      Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

      Data Element Name: Initial Hunt and Hess Scale Performed

      Collected For: CSTK-03

      Definition: Documentation of the first Hunt and Hess scale that was done at this hospital. The Hunt and Hess scale is a grading system used to classify the severity of a subarachnoid hemorrhage based on the patient's clinical condition. The scale ranges from a score of 1 to 5. It is used as a predictor of prognosis/outcome with a higher grade correlating to a lower survival rate.

            Grade - Description

             1 (I) - Asymptomatic, mild headache, slight nuchal rigidity
             2 (II) - Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy
             3 (III) - Drowsiness / confusion, mild focal neurologic deficit
             4 (IV) - Stupor, moderate-severe hemiparesis
             5 (V) - Coma, decerebrate posturing

      Suggested Data Collection Question: Was an initial Hunt and Hess scale done at this hospital?

      Format

      Length:
      1
      Type: Alphanumeric
      Occurs: 1

      Allowable Values:

      Y (YES) Initial Hunt and Hess scale was done at this hospital.

      N (No) Initial Hunt and Hess scale was not done at this hospital, OR Unable to determine (UTD) from the medical record documentation.

      Notes for Abstraction:

      • The Hunt and Hess scale may be documented by the physician/APN/PA or nurse (RN).
      • Hunt and Hess obtained by teleneurology and documented in the medical record, select 'YES'.

      Suggested Data Sources:

      • Consultation notes
      • Emergency department record
      • History and physical
      • Progress notes
      • Admitting note

      Guidelines for Abstraction

      Inclusion:

      • Hunt and Hess "1-5"
      • Hunt and Hess Grade
      • Hunt and Hess Scale
      • Hunt & Hess "1-5"
      • H/H "1-5"
      • Hunt & Hess "1-5"/Fischer "X"
      • SAH Grade "1-5"
      • Grade "1-5" SAH

      Exclusion: None

      Summary of Changes

      OPTIONAL COMPREHENSIVE: If yes, Hunt and Hess score

      If the Hunt and Hess Scale was performed, what is the first score recorded by hospital personnel.  Score documentation may range from 1 to 5.

      Notes for Abstraction:

      • Enter the total score of the first Hunt and Hess Scale performed within 6 hours of hospital arrival and prior to the initiation of any invasive intracranial procedure.
      • First Hunt and Hess scale can be recorded by a physician/APN/PA or nurse.

      1.   Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968;28:14 –20..
      2.  Connolly ES, Jr., Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43:1711-1737.

      https://osstatic.irp.iqvia.com/online_doc_qi/StrokePMT/coding_instruction/source.jpgEmergency Department Data, Admission Data

      Summary of Changes

      REQUIRED FOR COMPREHENSIVE: What is the date and time that the Hunt and Hess Scale was first performed at this hospital?

      Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

      Data Element Name: Initial Hunt and Hess Scale Date/Time

      Collected For: CSTK-03

      Definition: The month, date, year, and time (military time) that the Hunt and Hess scale was first performed at this hospital. The Hunt and Hess scale is a grading system used to classify the severity of a subarachnoid hemorrhage based on the patients clinical condition. It is used as a predictor of prognosis/outcome with a higher grade correlating to a lower survival rate.

      Suggested Data Collection Question: What is the date and time that the Hunt and Hess scale was first performed at this hospital?

      Format

      Length:
      10 - MM-DD-YYYY (includes dashes) or UTD, 5 - HH-MM (with or without colon) or UTD
      Type: Date/Time
      Occurs: 1

      Allowable Values:

      MM = Month (01-12)
      DD = Day (01-31)
      YYYY = Year (2001-Current Year)
      UTD = Unable to Determine

      HH = Hour (00-23)
      MM = Minutes (00-59)
      UTD = Unable to Determine

      Notes for Abstraction:

      • Use the date that the Hunt and Hess scale was first performed. If a discrepancy exists in date documentation from different sources, choose the earliest date. If there are two or more initial Hunt and Hess scale dates (either different Hunt and Hess assessments or corresponding with the same assessment), enter the earliest date.
      • If the initial Hunt and Hess scale date is unable to be determined from medical record documentation, select UTD.
      • The medical record must be abstracted as documented (taken at face value). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD.
        Example:
        Documentation indicates the initial Hunt and Hess scale date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the initial Hunt and Hess scale date is outside of the range listed in the Allowable Values for Day, it is not a valid date and the abstractor should select UTD.
        Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commissions Data Warehouse. Use of UTD for Initial Hunt and Hess Scale Date allows the case to be accepted into the warehouse.
      • Use the time for which the Hunt and Hess scale was first performed. If a discrepancy exists in time documentation from different sources, choose the earliest time. If there are two or more different initial Hunt and Hess scale times (either different Hunt and Hess assessments or corresponding with the same assessment), enter the earliest time.
      • If the time of the first Hunt and Hess is a time prior to hospital arrival because the score was obtained by teleneurology or MD/APN/PA directly receiving the patient via life flight, use the Arrival Time for the score time.
      • For times that include seconds, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00
      • Initial Hunt and Hess Scale Time refers to the time that the first Hunt and Hess Scale was performed. If the time performed is mentioned in the body of a note, select the time performed rather than the time stamp on the note. If the only time documented with the scale is the time stamp on the note, then select the time stamped. Examples:
        • Documentation indicates that the initial Hunt and Hess scale was done at 0920. Time stamp on the note is 1159. The abstractor should select 0920 for Initial Hunt and Hess Scale Time.
        • Documentation indicates that the Hunt and Hess done on arrival was III. Patient arrived at your hospital 2100. Time stamp on the note is 2136. The abstractor should select 2100 for Initial Hunt and Hess Scale Time.
        • Hunt & Hess 3 [no time] documented. Time stamp on the note is 1513. The abstractor should select 1513 for Initial Hunt and Hess Scale Time.
      • Do not use physician orders as they do not demonstrate the Hunt and Hess scale was done (in the ED this may be used if signed/initialed by a nurse).
      • If the time of the first Hunt and Hess scale is unable to be determined from medical record documentation, select UTD.
      • The medical record must be abstracted as documented (taken at face value). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select UTD.
        Example:
        Documentation indicates the initial Hunt and Hess scale time was 3300. No other documentation in the medical record provides a valid time. Since the initial Hunt and Hess scale time is outside of the range listed in the Allowable Values for Hour, it is not a valid time and the abstractor should select UTD.
        Note: Transmission of a case with an invalid time as described above will be rejected from the Joint Commissions Data Warehouse. Use of UTD for Initial Hunt and Hess Scale Time allows the case to be accepted into the warehouse.

      Suggested Data Sources:

      • Consultation notes
      • Emergency department record
      • History and physical
      • Progress notes
      • Admitting note

      Guidelines for Abstraction

      Inclusion: None

      Exclusion: None

      Summary of Changes

      OPTIONAL COMPREHENSIVE: WFNS SAH Grading Scale

      The World Federation of Neurologic Surgeons grading scale is a scale for grading patients with a subarachnoid hemorrhage. Enter a value of 1-5.


      Medications Prior to Admission

      Summary of Changes

      Required: Antiplatelet or Anticoagulant Medication(s):

      Is there documentation that the patient was on any antiplatelet or anticoagulant medication(s) prior to hospital arrival?

      • Yes: There is documentation that the patient has taken any antiplatelet or anticoagulant medication(s) within the past week and prior to hospital arrival. See Table 4 & Table 5 for a list of antiplatelet and anticoagulant medications.
      • No/ND: The patient has not been taking any antiplatelet or anticoagulant medication(s) within the past week or there is no documentation relating to medications prior to arrival, or those medications are listed as unknown.

      Notes for Abstraction:

      • If documentation in the medical record indicates that therapy has been prescribed but patient has not filled the prescription, has not taken the medication in the past week or is otherwise noncompliant, answer “No/ND” to this data element.

      Required: Antiplatelet Class: See Table 4 for a list of antiplatelet medications

      Check the box if the patient was taking any antiplatelet medication(s) prior to arrival.

      REQUIRED: Antiplatelet Medication (Specify):

      If the patient was taking any antiplatelet medication(s) prior to arrival, select the specific medication.

        • aspirin
        • aspirin/dipyridamole (in separate formulations or as Aggrenox)
        • clopidogrel (Plavix)
        • prasugrel (Effient)
        • ticagrelor (Brilinta)
        • ticlopidine (Ticlid)
        • Other Antiplatelet

      REQUIRED: Anticoagulant Class: See Table 5 for a list of anticoagulant medications 

      Check the box if the patient was taking any anticoagulant medication(s) prior to arrival.

      REQUIRED: Anticoagulant Medication (Specify):

        • apixaban (Eliquis)
        • argatroban
        • dabigatran (Pradaxa)
        • desirudin (Iprivask)
        • edoxaban (Savaysa)
        • fondaparinux (Arixtra)
        • full does LMW heparin
        • lepirudin (Refludan)
        • rivaroxaban (Xarelto)
        • Unfractionated heparin IV
        • Wafarin (Coumadin)
        • Other Anticoagulant

      Admission Data, Hospitalization Data

      Summary of Changes

      REQUIRED FOR COVERDELL ONLY: Antihypertensive

      Is there documentation that the patient was on any antihypertensive medication prior to hospital arrival?

      • Yes: There is documentation that the patient has taken any antihypertensive medication within the past week and prior to hospital arrival
      • No/ND: The patient has not taken any antihypertensive medications within the past week or there is no documentation relating to medications prior to arrival, or those medications are listed as unknown

      Notes for Abstraction:

      • If documentation in the medical record indicates that therapy has been prescribed but patient has not filled the prescription or is otherwise noncompliant, answer “No/ND” to this data element.
      •  See Table 1 for a list of antihypertensive medications

      Admission Data, Hospitalization Data

      Summary of Changes

      REQUIRED: Cholesterol-Reducer

      Is there documentation that patient was on a lipid-lowering medication prior to hospital arrival?

      • Yes: There is documentation that the patient was on a lipid-lowering medication (cholesterol-reducing/controlling medication) prior to hospital arrival.
      • No/ND: There is no documentation that the patient was on a lipid-lowering medication (cholesterol-reducing/controlling medication) prior to hospital arrival or unable to determine from medical record documentation.

      Notes for Abstraction:

      • Evidence in the medical record of a medication in the cholesterol-reducing class at a given dosage and frequency of administration is adequate to answer “Yes” to this data element. See Table 2 for a list of acceptable Lipid-Lowering (cholesterol-reducing) medications.
      • If there is documentation that the patient was on a lipid-lowering medication at home but there is indication it was on temporary hold or the patient has been non-compliant/self-discontinued their medication (e.g., refusal, side effects, cost), select “Yes”.
      • When conflicting information is documented in a medical record, select “Yes”.
      • Refer to Table 2 for a comprehensive list of Lipid-Lowering (cholesterol-reducing) medications. 

      Example:

      • Patient 120a is admitted to the in-patient unit with right hemiparesis and dysarthria. His pre-admission medications were lisinopril, aspirin, metformin and furosemide. Data entry will be to check "No/ND".
      • Patient 120b says they are on a cholesterol pill, but cannot identify the drug name or dose. Date entry will be to check "Yes".

      Admission Data, Hospitalization Data

      Summary of Changes

      Anti-Hyperglycemic Medications

      Collected For: Target: Type 2 Diabetes

      Definition: Documentation that the patient was on any anti-hyperglycemic medication prior to arrival.

      Question: Is there documentation that the patient was on any anti-hyperglycemic medication prior to hospital arrival?

      Format: Single Select

      Allowable Values:

      • Yes
      • No/ND

      Notes for Abstraction:

      • Yes: There is documentation that the patient has taken any anti-hyperglycemic medication within the past week and prior to hospital arrival.
      • No/ND: The patient has not taken any anti-hyperglycemic medications and/or there is no documentation relating to medications prior to arrival, or those medications are listed as unknown.
      • If documentation in the medical record indicates that therapy has been prescribed but patient has not filled the prescription or is otherwise noncompliant, answer "No" to this data element.
      • Example: Patient 130a is admitted to the inpatient unit with right hemiparesis and dysarthria. His pre-admission medications were lisinopril, aspirin, metformin and fursoemide. His metformin is held but all other medications are continued. Data abstractor would select "Yes."

      Suggested Data Source:

      • Admission Data
      • Hospitalization Data

      Additional Notes/ Guidelines for Abstraction: N/A

      Summary of Changes

      If yes (Anti-Hyperglycemic), select medications

      Collected For: Target Type 2 Diabetes

      Definition: Documentation of the type of anti-hyperglycemic medication the patient was on prior to hospital arrival.

      Question:If yes, the patient was on any anti-hyperglycemic medication prior to arrival select the medication(s).

      Format: Multi-Select

      Allowable Values:

      • DPP-4 Inhibitors
      • GLP-1 Receptor Agonist
      • Insulin
      • Metformin
      • SGLT2 Inhibitor
      • Sulfonylurea
      • Thiazolidinedione
      • Other oral agents
      • Other injectable/ subcutaneous agents

      Notes for Abstraction:

      • Select the class of anti-hyperglycemic medication(s) the patient is prescribed upon arrival to your hospital.
      • Reference Table 7 for list of anti-hyperglycemic medications and classes.

      Suggested Data Sources:

      • Admission Data
      • Hospitalization Data

      Additional Notes/ Guidelines for Abstraction: N/A

      Summary of Changes

      OPTIONAL: Antidepressant Medication

      Definition: Depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for an extended period. Is there documentation that the patient was on any antidepressant medication prior to hospital arrival?

      Data Collection Question:
      Is there documentation that the patient was on any diabetic medication prior to hospital arrival?

      Format: Single-select
      Allowable Values:
      • Yes
      • No/ND

      Notes for Abstraction:

      • Yes: There is documentation that the patient has taken any antidepressant medication within the past week and prior to hospital arrival.
      • No/ND: The patient has not taken any antidepressant medications within the past week or there is no documentation relating to medications prior to arrival, or those medications are listed as unknown.
      • If documentation in the medical record indicates that therapy has been prescribed but patient has not filled the prescription or is otherwise noncompliant, answer "No/ND" to this data element.
      • Antidepressant classes include tricyclic and tetracyclic antidepressants [TCAs; imipramine (Tofranil), amitriptyline (Elavil), nortriptyline (Pamelor), doxepin (Sinequan)]; selective serotonin reuptake inhibitors [SSRIs; Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil, Pexeva) Sertraline (Zoloft)]; serotonin and norepinephrine reuptake inhibitors (SNRIs; Duloxetine (Cymbalta), Venlafaxine (Effexor XR), Desvenlafaxine (Pristiq)]; monoamine oxidase inhibitors [MAOIs Isocarboxazid (Marplan), Phenelzine (Nardil),Selegiline (Emsam),Tranylcypromine (Parnate)]; norepinephrine reuptake inhibitors [NRIs; Bupropion (Wellbutrin), Teniloxazine (Lucelan), Reboxetine (Edronax]; norepinephrine-dopamine reuptake inhibitors (NDRIs), serotonin receptor antagonists/agonists, and 2-adrenergic receptor antagonists.
      Suggested Data Source:
      • Emergency department record
      • History and physical
      • Admitting note

      Vaccinations & Testing

      COVID-19 Vaccination

      Collected For: GWTG

      Definition: Documentation whether or not the patient received a COVID-19 vaccination.

      Question For: Did the patient receive a COVID-19 vaccination prior to or during hospitalization?

      Format: Single Select

      Allowable Values:

      • COVID-19 vaccine was given during this hospitalization.
      • COVID-19 vaccine was received prior to admission, not during this hospitalization.
      • Documentation of patient's refusal of COVID-19 vaccine
      • Allergy/ sensitivity to COVID-19 vaccine or if medically contraindicated
      • Vaccine not available
      • None of the above/ Not documented/ UTD.

      Notes for Abstraction:

      • Select the response that best fits the patient's vaccination status.
      • If a patient received the vaccine as part of a COVID-19 vaccine trial, then select the appropriate option above (during hospitalization or Prior to hospitalization) and document "Yes" for the question below, "Is there documentation that this patient was included in a COVID-19 vaccine trial?".

      Suggested Data Sources:

      • Admission Data
      • Discharge Data

      Additional Notes / Guidelines for Abstraction: N/A

      Summary of Changes


      COVID-19 Vaccination Date

      Collected For: GWTG

      Definition: Documentation of the date of the COVID-19 vaccination

      Question For: What date was the COVID-19 vaccination administered?

      Format: MM/DD/YYYY

      Allowable Values:

      • Date: MM/DD/YYYY
        • MM = Month (01-12)
        • DD = Day (01-31)
        • YYYY = Year (2012 - Current Year)
      • Unknown

      Notes for Abstraction:

      • Only report the date the vaccine was given if it was administered during this hospitalization.
      • Document the Date of the first dose of vaccine administration
      • Select "Unknown" if the date is not documented.

      Suggested Data Sources:

      • Admission Data

      Additional Notes / Guidelines for Abstraction: N/A

      Summary of Changes


      COVID-19 Vaccine Manufacturer

      Collected For: GWTG

      Definition: Documentation of the manufacturer of the COVID-19 vaccine.

      Question For: Who was the manufacturer of the COVID-19 vaccine?

      Format: Single Select

      Allowable Values:

      • AstraZeneca
      • Johnson & Johnson's / Janssen
      • Moderna
      • Novavax
      • Pfizer
      • Other
      • Not Documented

      Notes for Abstraction:

      • N/A

      Suggested Data Sources:

      • Admission Data

      Additional Notes / Guidelines for Abstraction: N/A

      Summary of Changes


      Did the patient receive both doses of vaccine? (if applicable)

      Collected For: GWTG

      Definition: Documentation that the patient received both doses of a two-dose COVID-19 vaccine.

      Question For: Did the patient receive both doses of vaccine? (if applicable)

      Format: Single Select

      Allowable Values:

      • Yes
      • No
      • Not Applicable

      Notes for Abstraction:

      • Select "No" if the patient has received only one dose of a two-dose COVID-19 vaccine.
      • Select "Not applicable" if the COVID-19 vaccine the patient received only requires one dose (e.g., Johnson & Johnson's / Janssen).

      Suggested Data Sources:

      • Admission Data

      Additional Notes / Guidelines for Abstraction: N/A

      Summary of Changes


      Is there documentation that this patient was included in a COVID-19 vaccine trial?

      Collected For: GWTG

      Definition: Documentation of if the patient was included in a COVID-19 vaccine trial.

      Question For: Is there documentation that this patient was included in a COVID-19 vaccine trial?

      Format: Single Select

      Allowable Values:

      • Yes
      • No/ ND

      Notes for Abstraction:

      • N/A

      Suggested Data Sources:

      • Admission Data
      • Hospitalization Data

      Additional Notes / Guidelines for Abstraction: N/A

      Summary of Changes


      Influenza Vaccination

      Collected For: GWTG

      Definition: Documentation whether or not the patient received an influenza vaccination.

      Question For: Did the patient receive an influenza vaccination prior to or during hospitalization?

      Format: Single Select

      Allowable Values:

      • Influenza vaccine was given during this hospitalization during the current flu season.
      • Influenza vaccine was received prior to admission during the current flu season, not during this hospitalization.
      • Documentation of patient's refusal of influenza vaccine
      • Allergy/ sensitivity to influenza vaccine or if medically contraindicated
      • Vaccine not available
      • None of the above/ Not documented/ UTD.

      Notes for Abstraction:

      • Select the response that best fits the patient's vaccination status.

      Suggested Data Sources:

      • Admission Data

      Additional Notes / Guidelines for Abstraction: N/A

      Summary of Changes


      Hospitalization Tab:

      Symptom Timeline

      REQUIRED: Date/Time patient last known to be well?


      Required Field, Modification to response required for TJC/CM form group
      TJC/CM User Note:Adjustments need to be made on the Core Measure tab for patients with transient symptoms that fully resolve and later return. Per TJC, you should enter the earliest last known well for this type of patient (those that have transient symptoms that fully resolve and later return while in the ED).Per STK-4 specifications, time last known well must be before the arrival time or the patient will be assigned to category 'X' for missing/invalid data.

      To meet both GWTG and TJC definitions, for cases such as these, click into the Core Measure tab and change the auto populated response for the data element "What was the date and time at which the patient was last known to be well or at his or her baseline state of health?" to the earliest time recorded following the appropriate hierarchy.


      Definition: The date and time at which the patient was last known to be without the signs and symptoms of the current stroke or at his or her prior baseline.



      Format: Single-select
      • MM = Month (01-12)
      • DD = Day (01-31)
      • HH = Hour (00-23)
      • MM = Minutes (00-59)
      • UTD = Unable to Determine


      Allowable Values: Date and Time (military time) or UTD

      Notes for Abstraction:

      • The purpose of this data element is to identify the earliest possible time that stroke symptoms began. This is sometimes known as "Onset Time" although the use of this term has been confusing to many in the past. If a patient experiences the onset of their symptoms in the company of another individual who can verify that the patient was functioning normally up until the time of start of symptoms, then in this patient the time "last known well" is also the time of symptom discovery. In many cases, however, no one is present at the exact start of symptoms. In this situation, we need to document the time when symptoms were first discovered (time of symptom discovery) as well as the time that the patient was last known to be well or at their baseline (time last known well), and record both of these.
      • The time last known well should be the time closest to the time of discovery for which we have clear evidence that the patient was at their previous baseline. Depending on the type of stroke symptoms, this might be established by a telephone or in person conversation. Family members, EMS personnel, and others, often mistakenly record the time of symptom discovery as the time the patient was last known well. It is imperative to distinguish these two times to avoid inappropriate use of IV alteplase (Intravenous Tissue Plasminogen Activator) in patients who are recently discovered to have symptoms but are many hours (>3 hrs) from their time of last being well.
      • If a stroke "onset time" is listed in the medical record, without reference to the circumstances preceding its detection, then it should be assumed to be the time "last known well". Enter this time in the specified format.
      • If there is a specific reference to the patient having been discovered with symptoms already present, then this "onset time" should be treated as a "time of symptom discovery" rather than a time of "last known well". If no time of "last known well" can be determined, then "Unknown" should be selected for time "last known well".
      • When a time of discovery is documented, but the start of stroke symptoms is not witnessed and no time "last known well" is documented, then "Unknown" should be selected for time "last known well".
      • When the start of stroke symptoms is clearly witnessed, then the time "last known well" is identical to the time of symptom discovery.
      • If the time of "last known well" is documented as being a specific number of hours prior to arrival (e.g., 2 hours ago) rather than a calendar time, subtract that number from the time of hospital or ED arrival and enter that time as the time "last known well."
      • If the time of "last known well" is noted to be a range of time prior to hospital or ED arrival (e.g., "2 - 3 hours ago"), assume the maximum time from the range (e.g., 3 hours), and subtract that number of hours from the time of arrival to compute the time "last known well".
      • If there are multiple times of "last known well" documented, either because subsequent more accurate information became available or because of different levels of expertise in sorting out the actual time of "last known well", use the time recorded according to the following hierarchy:
        1. neurology
        2. admitting physician
        3. emergency department physician
        4. ED nursing notes
        5. EMS
      • If multiple date/times of last know well are documented by the same provider, use the earliest date recorded by that provider.
      • The purpose of 'last known well' is to conservatively identify/estimate time of symptom onset. Use "last known well" to identify when the patient was either last seen or last known to be well (well means at the patient's baseline or usual state of health). This may change with various observers. If the last known well time cannot be identified, then indicate that last known well time and/or date is not known.
      • In certain selected cases, patients may have transient symptoms which resolve and are later followed by symptoms that do not resolve and result in admission to the hospital. If there is documentation of one or more symptomatic episodes of transient stroke symptoms and documentation of symptom resolution between episodes (e.g. patient returns to baseline), then enter the date/time of the most recent (last) episode here (even if it occurs after hospital arrival and prior to hospital admission).  The following terms may be used as documentation that a patient has experienced transient symptoms and has subsequently returned to baseline:
          • “baseline”; “symptoms resolved/symptom free/no further symptoms”;  “without further stroke symptoms”; “complete reversal of symptoms”; “NIHSS = 0”; “resolved TIA”; “deficit free/no deficits”.
          • The following terms would constitute documentation of recurrence of stroke symptoms. 
            • “symptoms returned;” “new onset of symptoms;” “recurrence of symptoms;” “increase NIHSS”.
          • Example:  Patient with right sided weakness at home on 08/31/2012 at 0800.  Upon arrival to the hospital, physician documents that the patient is symptom free and documents an NIHSS of zero.  Facial droop noted at 1030 while the patient is in the ED.  Repeat NIHSS performed and documented as 3.  Enter date/time of 08/31/2012 1030.
      • TJC/CM User Note: Adjustments need to be made on the Core Measure tab for patients with transient symptoms that fully resolve and later return. Per TJC, you should enter the earliest last known well for this type of patient (those that have transient symptoms that fully resolve and later return while in the ED). Per STK-4 specifications, time last known well must be before the arrival time or the patient will be assigned to category 'X' for missing/invalid data. In order to meet both GWTG and TJC definitions, for cases such as these, click into the Core Measure tab and change the auto populated response for the data element "What was the date and time at which the patient was last known to be well or at his or her baseline state of health?" to the earliest time recorded following the appropriate hierarchy.

      Examples:

      1. Patient 140a arrived in ED via EMS on 12/10/20XX at 14:43 accompanied by her daughter. Her daughter states that patient was found at 2:00 pm "in her chair slumped over, I couldn't understand what she was saying and she was drooling from her mouth - and her face didn't look right." On further questioning by the neurologist, the daughter says her mother ate lunch at 12:30 pm and then went to sit in her chair where she was later found as noted above. Date and Time of last known well are known as 12/10/20XX 12:30, and Date and Time of discovery are known as 12/10/20XX 14:00.
      2. Patient 140b arrived in the ED with his son on 11/10/20XX 8:09 am. His son states that he last saw his father last night at 8:30 pm. His father lives alone. His father woke up this morning about 6:30 am and noticed that his right arm was weak. It did not get better, so patient called his son at 7:00 am, who came over right away and was concerned that his father was having a stroke, but his father could walk and talk OK. Daughter arrives and states that she had talked to her father on the phone last night around 9:30 pm and that he didn't mention anything about a problem with his arm. Date and Time of last known well are known as 11/09/20XX 21:30, and Date and Time of discovery are known as 11/10/20XX 06:30.
      3. Patient 140c was eating dinner with his wife tonight after they finished watching the nightly news on TV "when his arm began shaking and he couldn't hold onto his fork or his water glass or anything. He has never done this before." Their nightly news show is on from 6:00 to 6:30 pm. She called the ambulance right away. ED arrival date and time is 11/29/20XX 7:53 pm. Date and Time of last known well are known as 11/29/20XX 18:30, and date of discovery is known as 11/29/20XX with an unknown time. There is no reference to time of discovery in this scenario, so it remains unknown to the abstractor. Above the Date/Time field, select "MM/DD/YYYY" and just enter 11/29/20XX.
      4. Patient 140d states she has been having numbness come and go in her left arm for the past week, but it always went away. Today the numbness started about 4 hours before she came to the ED and didn't go away so she decided to get it checked. She thinks her arm isn't completely numb, but it feels heavy, and she can't hold a pen tightly. ED arrival time is 5:15 pm on 09/09/20XX. Date and Time of last known well are known as 09/09/20XX 13:15, and Date and Time of discovery are known as 09/09/20XX 13:15.
      5. Patient 140e was found on the floor beside the commode by the charge nurse at Starlight Nursing Home on her night rounds at 12:45 am on 12/01/20XX. He wasn't able to talk or move, but his left leg was shaking. He is normally quite alert and normally walks with his walker. Date and Time of last known well are known as 11/30/20XX 21:00, and Date and Time of discovery are known as 12/01/20XX 00:45.
      6. A 58 y/o woman was last known normal at 7:00 pm and was found at 7:30 pm with right hemiparesis and aphasia. She is transferred to your hospital from another hospital having IV alteplase initiated on 06/10/20XX at 9:30 pm and arrived at your hospital at 10:15 pm. Date and Time of last known well are known as 06/10/20XX 19:00, and Date and Time of discovery are known as 06/10/20XX 19:30.
      7. A 55 year old male had a brief episode of slurred speech at 6am on 5/10/20XX. The episode resolved quickly and he returned completely to normal. At Noon on that same day (5/10/20XX) he developed one sided weakness and slurred speech which persisted when he arrived to your hospital. Date and Time of last known well are known as 5/10/20XX 12:00.
       

      Admission Data, Hospitalization Data

      Summary of Changes

      REQUIRED: Date/Time of discovery of stroke symptoms? (When was the patient first discovered to have the current stroke symptoms?)

      Indicate the date and time of discovery of patient's symptoms (i.e., when the patient was found with symptoms). This should be the earliest time that patient was known to have symptoms. This date and time should not vary. If the event was witnessed, then the last known well date and time and the discovery date and time will be identical. Record both, even if identical (checking the box for Time of Discovery same as Last Known Well will automatically set the discovery Date/Time with the same Date/Time as "last known well".)

      • Date:MM/DD/YYYY
      • Time: HH:MM
      • 24-hour clock (military time)

        See examples from Last Known Well

        Admission Data, Hospitalization Data

      Summary of Changes

      OPTIONAL: Time of Discovery same as Last Known Well

      When the onset of symptoms is clearly witnessed, then the time "last known well" is identical to the time of symptom discovery. If this is the case, check this box to automatically fill-in discovery Date/Time with the same Date/Time as "last known well".


      Brain Imaging

      OPTIONAL: Was brain or vascular imaging performed prior to transfer to your facility?

      (Was brain or vascular imaging performed at an outside hospital prior to transfer to your facility as part of the initial evaluation?)

      • Yes: Patient did receive brain or vascular imaging at an outside hospital prior to transfer to your facility as part of the acute evaluation.
      • No/ND: Patient did not receive any brain or vascular imaging at an outside hospital prior to transfer to your facility.

      Notes for Abstraction:

      • This element is only available in the MER/CSTK form groups.
      • The element is enabled in ischemic stroke patients who are transferred to your facility from an outside hospital.
      • Select "Yes" if imaging was conducted by the outside hospital as part of the patient's acute evaluation for ischemic stroke.
      • If you are unable to obtain any information indicating brain or vascular imaging from the hospital at which the patient received brain or vascular imaging prior to transfer, select "No/ND."
      • If you are unable to determine that brain or vascular imaging was done from the outside hospital's documentation, but are not able to determine the specific type of imaging. Select "Yes" to "Did patient receive brain or vascular imaging prior to transfer to your hospital". You would then answer: "Image Type not documented" for the subsequent data element "If yes, which imaging tests were performed?"
      • Note that the Federal Privacy Rule (HIPAA) does not restrict the communication of protected health information when performed for quality assurance purposes.

      Admission Data, Hospitalization Data, especially Radiology notes

      Summary of Changes

      OPTIONAL: If yes, which imaging tests were performed?

      (Indicate which imaging tests were performed at the outside hospital prior to transfer to your facility)

      • CT
      • CTA*
      • CT Perfusion*
      • MRI
      • MRA*
      • MR Perfusion*
      • Image type not documented

      Notes for Abstraction:

      • This element is only available in the MER/CSTK form groups.
      • The element is enabled in ischemic stroke patients who are transferrred to your facility from an outside hospital and who have "Yes" selected for "Was brain or vascular imaging performed prior to transfer to your facility?".
      • If you are unable to determine the specific type of imaging completed at the outside hospital, but know imaging was done. Select "Yes" to "Did patient receive brain or vascular imaging prior to transfer to your hospital". You would then answer: "Image Type not documented" for the subsequent data element "If yes, which imaging tests were performed?"
      • Below are definitions of the different imaging modalities:
        • CT: Non-contrast computed tomography
        • CTA: Computed tomogrpahy Angiography*
        • CT Perfusion: Computed tomography perfusion*
        • MRI: Magnetic Resonance Imaging
        • MRA: Magnetric Resonance Angiography*
        • MR Perfusion: Magnetric Resonance with Perfusion*
        • Image type not documented

      Admission Data, Hospitalization Data, especially Radiology notes

      Summary of Changes

      OPTIONAL: Date/time 1st vessel or perfusion imaging initiated prior to transfer?

      (The date and time that additional imaging was performed at the outside hospital, prior to transfer to diagnose large vessel occlusion (LVO)).

      • Date: MM/DD/YYYY
      • Time: HH:MM 24-hour clock (military time)
      • Unknown
      • Record the date and time that additional imaging was performed at the outside hospital, prior to transfer, to diagnose large vessel occlusion (LVO).
      • This is the date and time for advanced imaging ONLY. *This date/time element will only enable if the imaging tests performed at the outside hospital include CTA, CT Perfusion, MRA or MR Perfusion.
      • If you cannot find the date and time the advanced imaging was performed prior to transfer, select "Unknown" from the date/time drop down.

      Admission Data, Hospitalization Data, especially CT study and Radiology notes

      Summary of Changes

      REQUIRED: Brain imaging at your hospital for this episode of care?

      (Was brain imaging performed at your hospital after arrival as part of the initial evaluation for this episode of care or this event?)

      • Yes: Patient did receive brain imaging at your hospital/facility for this event
        • If yes, indicate the type of brain imaging completed (select all that apply)
        • CT
        • MRI
      • No/ND: Patient did not receive any brain imaging at your hospital/facility or did not receive imaging at an outside hospital prior to transfer
      • NC: Patient had outside brain imaging prior to transfer from another hospital, and results for that imaging are recorded in the record

      Notes for Abstraction:

      • This data element is looking to capture information around the initial brain image for this event (regardless if it is done at your facility or not). If a second brain image is completed at your hospital, after an initial imaging has been completed at an outside hospital, you would still select NC here and would record the findings of the initial brain image that was performed at the outside facility under Interpretation of first brain image after symptom onset, done at any facility.
      • For inpatient stroke, use the first brain image performed after discovery of stroke symptoms in the hospital. If patient had brain imaging performed in the hospital prior to stroke symptom onset, use the brain imaging performed after discovery of stroke symptoms in the hospital.
        • If the patient arrives to the hospital with transient symptoms that resolve and brain imaging is completed, but later in the hospital stay the patient has new onset stroke symptoms and meets criteria to be entered as an inpatient stroke, new brain imaging should be performed.  If new brain imaging is not performed, select "No/ND."  Do NOT use brain imaging performed for the prior resolved event. 

      Example: Patient 150a presented to the ED with a brief episode of slurred speech. The patient had a CT and lab tests completed. Symptoms completely resolved while in the ED and the patient was discharged from the ED with complete recovery of neurological symptoms. The patient returned to the ED 3 hours later and no repeat CT or lab tests were completed, but the previous CT and labs are used to determine course of treatment. Select NC for Brain Imaging Completed at this hospital.

      Admission Data, Hospitalization Data, especially Radiology notes

      Summary of Changes

      REQUIRED: Date/Time Brain Imaging Initiated

      Enter date and time of the initial non-contrast CT/MRI of the head performed at your institution from the DICOM header information. This is the date and time printed on the hard copy of the film or available when reviewing the image digitally. For CT studies, use the date-time stamp on the non-contrast CT, not from CT-angiography or CT-perfusion studies, if they were done. Record only CT/MRI date/time if the first study was performed at your hospital. Please note, use the time indicated on the radiology report only if it clearly indicates the time of study initiation or completion (time of initiation preferred) and NOT time of scheduling, dictation or reporting.

      • Date:MM/DD/YYYY
      • Time: HH:MM
      • 24-hour clock (military time)

      Admission Data, Hospitalization Data, especially CT study and Radiology notes

      Summary of Changes

      REQUIRED FOR COVERDELL ONLY: Interpretation of First Brain Image after Symptom Onset (done at any facility):

      Hemorrhage includes any intracranial hemorrhagic stroke. It is important that only new hemorrhages thought to be responsible for the current acute event should be used if checking hemorrhage. Do not mark hemorrhage for old hemorrhages found on imaging, which are not responsible for the current event.

      • Acute Hemorrhage
      • No Acute Hemorrhage
      • Not available

      Admission Data, Hospitalization Data, especially Radiology notes

      REQUIRED and REQUIRED FOR COVERDELL: Was Acute Vascular or reperfusion imaging (CTA, MRA, DSA) performed at your hospital?
      Required field for TJC or CSTK or users that have the "Advanced Stroke Care Tab" enabled



      Record if additional imaging was performed in the acute evaluation for the purpose of diagnosing large vessel occlusion (LVO) for the patient. Intent of the element is to determine if detection of large-vessel occlusion by means of noninvasive intracranial vascular imaging was performed prior to initiating clinical decisions for treatment. Most large strokes are caused by occlusion in ≥ 1 large vessel.

      Data Collection Question: Was vascular imaging (e.g. CTA, MRA, DSA) performed for diagnosing large vessel occlusion(s) prior to initiating treatment for acute ischemic stroke?


      Format: Single-select

      Allowable Values:

      • Yes
      • No


      Notes for Abstraction:
      • Select Yes if patient had noninvasive intracranial vascular imaging performed for diagnosing large vessel occlusion(s) prior to initiating treatment for acute ischemic stroke.
      • Select No if there was no advanced imaging assessed at your hospital for diagnosing large vessel occlusion(s) prior to initiating treatment for the patient.
      • Select No if no documentation in the patient's medical record or unknown.


      Suggested Data Source:
      • Radiology Reports/Notes
      • CT Study
      • Diagnostic test reports

      CONDITIONALLY REQUIRED: If yes, type of imaging (select all that apply):

      Below are response options for the advanced imaging modalities:

      • CTA: Computed tomography Angiography*
      • CT Perfusion: Computed tomography perfusion
      • MRI: Magnetic Resonance Imaging
      • >MRA: Magnetic Resonance Angiography
      • MR Perfusion: Magnetic Resonance with Perfusion
      • DSA (catheter angiography)
      • Image type not documented

      Admission Data, Hospitalization Data, especially CT study and Radiology notes

      Summary of Changes

      CONDITIONALLY REQUIRED: Date/Time 1st vessel or perfusion imaging initiated at your hospital

      (The date and time that additional imaging was performed at your hospital as part of the acute evaluation for the purpose of diagnosing large vessel occlusion (LVO))

      • Date: MM/DD/YYYY
      • Time: HH:MM 24-hour clock (military time)
      • Unknown
      • Record the date and time that additional imaging was performed as part of the acute evaluation for the purpose of diagnosing large vessel occlusion (LVO).
      • This is the date and time for advanced imaging ONLY.
      • If you cannot find the date and time the advanced imaging was performed in the medical record documentation, select "Unknown" from the date/time drop down.

      Admission Data, Hospitalization Data, especially CT study and Radiology notes

      Summary of Changes



      Useful Background Information form 2013 AHA/ASA Guidelines:
      CT Angiography
      Helical CT angiography (CTA) provides a means to rapidly and noninvasively evaluate the intracranial and extracranial vasculature in acute, subacute, and chronic stroke settings and thus to provide potentially important information about the presence of vessel occlusions or stenoses. The accuracy of CTA for evaluation of large-vessel intracranial stenoses and occlusions is very high and in some cases its overall accuracy approaches or exceeds that of digital subtraction angiography (DSA).
      The sensitivity and specificity of CTA for the detection of intracranial occlusions ranges between 92% and 100% and between 82% and 100%, respectively, with a positive predictive value of 91% to 100%.
      Because CTA provides a static image of vascular anatomy, it is inferior to DSA for the demonstration of flow rates and direction.

      MR Angiography
      Intracranial MR angiography (MRA) is performed in combination with brain MRI in the setting of acute stroke to guide therapeutic decision making. There are several different MRA techniques that are used for imaging intracranial vessels.
      They include 2-dimensional time of flight (TOF), 3-dimensional TOF, multiple overlapping thin-slab acquisition, and contrast-enhanced MRA.
      Intracranial MRA with nonenhanced TOF techniques has a sensitivity ranging from 60% to 85% for stenoses and from 80% to 90% for occlusions compared with CTA or DSA.
      Typically, TOF MRA is useful in identifying acute proximal large-vessel occlusions but cannot reliably identify distal or branch occlusions.

      Digital Subtraction Angiography
      DSA remains the "gold standard" for the detection of many types of cerebrovascular lesions and diseases. For most types of cerebrovascular disease, the resolution, sensitivity, and specificity of DSA equal or exceed those of the noninvasive techniques, including for arterial stenoses.
      However, if noninvasive imaging provides firm diagnostic findings, cerebral angiography may not be required.
      DSA is an invasive test and most likely will not be the initial imaging modality for emergency intracerebral evaluation of large-vessel occlusion in stroke because of the time necessary to perform the examination; a CTA or MRA can be performed in an additional 2 to 4 minutes during initial stroke evaluation (in a multimodal evaluation in process) and can obviate the need for catheter angiography.

      Source: Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013; 44:870–947.

      CONDITIONALLY REQUIRED: Was a target lesion (large vessel occlusion) visualized?

      Required field for CSTK or MER users that have the "Advanced Stroke Care Tab" enabled.
      Optional for GWTG-Stroke sites.



      Definition: Record if a proximal large vessel occlusion (LVO) was identified upon reviewing the advanced brain imaging (e.g. CTA, MRA, DSA). Intent of the question is to determine if patient had a large vessel intracranial occlusion in the imaging.

      Additional Information: 2015 Endovascular Guidelines: For patients who otherwise meet criteria for endovascular treatment, a noninvasive intracranial vascular study is recommended during the initial imaging evaluation of the acute stroke patient, but should not delay IV alteplase if indicated.

      Data Collection Question: Was there a presence of a large vessel occlusion upon reviewing the vascular imaging (e.g. CTA)?

      Format: Single-Select

      Allowable Values:
      • Yes: There was presence of large vessel occlusions identified (or visualized) upon reviewing the vascular imaging.
      • No/ND: There were no large vessel occlusions identified (or visualized) upon reviewing the vascular imaging OR No documentation in the medical record that indicates presence of large vessel occlusion for vascular imaging completed for this episode of care.


      Notes for Abstraction:
      • An occlusion is complete or near complete blockage of the artery.
      • A "target lesion" is referring to a proximal large vessel occlusion.
      • A large-vessel occlusion typically causes severe stroke and independently predicts poor neurological outcome, and is a stronger predictor of "neurological deterioration." Thus, detection of large-vessel occlusion by means of noninvasive intracranial vascular imaging greatly improves the ability to make appropriate clinical decisions.


      Suggested Data Source:
      • Consultation notes
      • Radiology Notes
      • CT Study

      CONDITIONALLY REQUIRED: If yes, select site of occlusion:

      Required field for CSTK or MER users that have the "Advanced Stroke Care Tab" enabled and CSTK Users, Unique to GWTG

      Optional for GWTG-Stroke sites.



      Note:The response option for this question may be different for TJC element (Site of Primary Vessel Occlusion).

      Definition: If the results of vascular imaging indicated presence of large vessel occlusion(s), record all the sites where the large vessel occlusions were visualized. Please note that most large strokes are caused by occlusion in ≥ 1 large vessel.

      Data Collection Question: For patients who had a vascular imaging study (e.g., CTA, MRA) completed and the results indicated a presence of a large vessel occlusion, where are the specific locations for the large vessel occlusion(s)?

      Format: Multi-Select field.

      Allowable Values:
    • Internal Carotid Artery (ICA)
      • Intracranial ICA
      • Cervical ICA
      • Other/UTD
    • Middle Cerebral Artery (MCA)
      • M1 Segment
      • M2 Segment
      • Other/UTD
    • Basilar Artery
    • Vertebral Artery
    • Other cerebral artery branch


    Notes for Abstraction:
    • Select all areas where a large vessel occlusion was visualized in the vascular imaging study..
    • If you select the parent response options (ICA or MCA), then you are required to select one of the options underneath (intracranial ICA, cervical ICA, M1, M2, or Other/UTD).
    • Select Other/UTD when not able to determine which vessel segment or artery not listed (e.g., M3, M4, etc.).
    • Select Other cerebral artery branch when the artery is not in the current list (e.g., ACA, PCA, etc.).


    • Suggested Data Source:
    • Diagnostic test records
    • Brain imaging reports
    • Radiology reports



    Additional Time Tracker

      General notation for this section:

    • Only respond to the data elements in this section for acute stroke or TIA patients that present initially to your facility. This section is not applicable to stroke patients received in transfer from an outside facility.
    • For all elements, response options are in MM/DD/YYYY HH24:MI format. You may enter a precision of date and time, date alone, or unknown. A set all active Date/Time fields check box is present at the top of the section. When checked, it will auto-populate all dates within the Additional Time Tracker section with the patient's arrival date. Please be certain that if this box is checked, and a patient receives treatment on a date that is later than the arrival date (e.g. patient arrives on 10/10/20XX at 23:45 and IV alteplase is ordered on 10/11/20XX at 00:20) that you go in and correct the auto-set date.

    OPTIONAL: Date/Time Stroke Team Activated

    Enter the earliest documented date and time that the Stroke Team was activated.

    • Date: MM/DD/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    Notes for Abstraction:

    • The stroke team is a designated group of practitioners with knowledge and expertise in the diagnosis and treatment of cerebrovascular disease. It may consist of, but is not limited to physicians, mid-level providers, nurses, and trainees.
    • May be referred to as Acute Stroke Team (AST) activation, Stroke Code Team activation, Code Stroke, Stroke Alert, etc.
    • Acute stroke teams can be activated or notified in a variety of ways including by telephone or pager system. A best practice would include a single call activation system. Visit the Target: Stroke webpage to access stroke clinical resources and best practices.
    • Select "NA" if the Stroke Team was not activated at your hospital.

    OPTIONAL: Date/Time Stroke Team Arrived

    Enter the earliest documented date and time that the Stroke Team arrived.

    • Date: MM/DD/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    Notes for Abstraction:

    • Arrival may be classified as the time that evaluation and management by the stroke team first began. This may be in-person at the bedside, by telephone, or by telemedicine (as per protocol).
    • A telephone call acknowledging that the stroke team has been consulted does not qualify as evaluation and management by the stroke team.
    • Select "NA" if the patient was not evaluated by members of the stroke team.

    Examples:

    • Patient presents to the ED on 02/25/20XX at 09:55am and is seen by the triage nurse and then by the ED resident, who is NOT part of the acute stroke team. The resident makes the decision to activate a stroke alert. The stroke team is paged, and the stroke nurse calls back at 10:05am to acknowledge that the team is coming to the ED. The stroke team nurse arrives in the ED at 10:10am and the Neurologist arrives at 10:12am. The date time/time of stroke team arrival should be documented as 8/31/20XX 10:10.
    • Patient arrives in the ED on 08/10/20XX at 11:05am. The ED physician evaluates the patient at 11:10am and calls the neurologist at home at 11:15am to discuss the case and receive recommendations. The date/time stroke team arrival should be documented as 08/10/20XX 11:15.

    OPTIONAL: Date/Time of ED Physician Assessment

    Enter the earliest documented date and time that an emergency department physician performs an assessment for a suspected stroke patient at your hospital.

    • Date: MM/DD/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    OPTIONAL: Date/Time Neurosurgical Services Consulted

    Enter the earliest documented date and time that neurosurgical services were consulted at your hospital.

    • Date: MM/DD/YYY
    • Time: HH:MM
    • 24-hour clock (military time)

    Notes for Abstraction:

    • Neurosurgical services could include: physicians, mid-level providers, or trainees.
    • Includes consults with neurosurgical personnel at outside facilities (e.g. facilities with neurosurgical services).
    • Select "NA" if neurosurgical services were not consulted.

    OPTIONAL: Date/Time Brain Imaging Ordered

    Enter the earliest documented date and time that the initial/first brain image was ordered at your hospital.

    • Date: DD/MM/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    Notes for Abstraction:

    • CT or MRI qualifies as brain imaging
    • Enter CT or MRI date/time only if the first study was performed at your hospital. If a patient had outside brain imaging prior to transfer from another hospital, select "NA."
    • Brain image order time may be obtained from, but is not limited to, computerized or manual order entry systems, emergency department notes, or radiology logs. A specific order time must be documented–mention of the need for imaging without an order date/time is not sufficient.

    OPTIONAL: Date/Time Brain Imaging Interpreted

    Enter the earliest documented date and time at which the initial/first imaging results were made available to the treating team.

    • Date: DD/MM/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    Notes for Abstraction:

    • CT or MRI qualifies as brain imaging
    • Enter CT or MRI interpretation date/time only if the first study was performed at your hospital. If a patient had outside brain imaging prior to transfer from another hospital, leave this element blank.
    • Results must be interpreted by a physician such as a radiologist, neurologist, or others with experience and expertise in interpreting CT and/or MRI.
    • Interpretation of the brain image does not have to be done on site. It can be performed off site by teleradiology.
    • If a patient had outside brain imaging prior to transfer from another hospital, select "NA."

    Example: Patient presents to the ED on 02/25/20XX at 09:55am. CT scan is initiated at 10:00am. At 10:10am the treating neurologist documents that the CT scan is consistent with acute stroke and does not preclude treatment with IV alteplase. At 10:40am an official radiology interpretation confirms these findings and the radiologist documents that the treating neurologist was notified. Enter 02/25/20XX 10:10 as the date/time brain imaging interpreted.

    OPTIONAL: Date/Time IV alteplase Ordered

    Enter the earliest documented date and time that IV thrombolytic therapy was ordered at your hospital.

      • Date: DD/MM/YYYY
      • Time: HH:MM
      • 24-hour clock (military time)

      Notes for Abstraction:

      • Thrombolytic therapy for stroke includes:
        • Activase
        • Alteplase
        • IV alteplase
        • Recombinant alteplase Tissue plasminogen activator
      • If IV thrombolytic therapy was administered at another hospital and patient was subsequently transferred to your hospital, leave this data element blank.
      • Select "NA" if the patient did not receive IV thrombolytic therapy.
      • IV alteplase order time may be obtained from, but it not limited to, computerized or manual order entry systems, emergency department notes, or pharmacy logs.

    OPTIONAL: Date/Time Lab Tests Ordered

    Enter the earliest documented date and time that initial lab tests were ordered at your hospital.

    • Date: DD/MM/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    Notes for Abstraction:

    • Lab tests include a complete blood cell count with platelet count, coagulation studies (PT, INR), and blood chemistries.
    • Select "NA" if the patient did not receive initial lab tests at your facility or if lab tests were performed but they did not include a complete blood cell count, coagulation studies, and blood chemistries

    OPTIONAL: Date/Time Lab Tests Completed

    Enter the earliest documented date and time that initial lab tests were completed at your hospital.

    • Date: DD/MM/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    Notes for Abstraction:

    • Lab tests include a complete blood cell count with platelet count, coagulation studies (PT, INR), and blood chemistries.

    OPTIONAL: Date/Time ECG Ordered

    Enter the earliest documented date and time that the initial ECG was ordered at your facility. If a patient did not receive an initial ECG at your facility, select "NA."

    • Date: DD/MM/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    OPTIONAL: Date/Time ECG Completed

    Enter the earliest documented date and time that the initial ECG was completed at your facility. If a patient did not receive an initial ECG at your facility, select "NA."

    • Date: DD/MM/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    OPTIONAL: Date/Time Chest X-ray Ordered

    Enter the earliest documented date and time that the initial Chest X-ray was ordered at your facility. If a patient did not receive an initial Chest X-ray at your facility, select "NA."

    • Date: DD/MM/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    OPTIONAL: Date/Time Chest X-ray Completed

    Enter the earliest documented date and time that the initial Chest X-ray was completed at your facility. If a patient did not receive an initial Chest X-ray at your facility, select "NA."

    • Date: DD/MM/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    IV Thrombolytic Therapy


    IV Thrombolytic Initiated at this Hospital

    Collected For: GWTG

    Definition: Intravenous (IV) thrombolytic was initiated as this hospital.

    Question: Is there documentation that IV thrombolytic was initiated at this hospital?

    Format: Single Select

    Allowable Values:

    • Yes
    • No

    Notes for Abstraction:

    • Yes: IV thrombolytic initiated at this hospital.
    • No: IV thrombolytic was not initiated at this hospital (even if there are documented contraindications or warnings to IV alteplase) OR unable to determine from medical record documentation.
    • When a "hang time" or "infusion time" for IV thrombolytic is documented in the medical record, select "Yes".
    • If IV thrombolytic therapy was administered at another hospital and patient was subsequently transferred to this hospital, select "No".
    • If the patient was transferred to this hospital with IV thrombolytic infusing, select "No".
    • Thrombolytic Therapy for stroke includes:
      • Activase
      • Alteplase
      • IV alteplase
      • Recombinant alteplase Tissue plasminogen activator
      • Tenecteplase
      • TNK
      • TNKase
    • If a patient begins treatment with IV thrombolytic, but does not get the full dose due to a medical reason like an elevated INR or a newly discovered history element, select "Yes".
    • If patient received IV thrombolytic in the ED in your hospital and was then transferred from your ED (without hospital admission) to another acute care hospital, select "Yes" here and select "Yes, not admitted" for "Not Admitted?" This will allow you to capture the "drip and ship patient and disable non-relevant questions. See instructions for "Not Admitted?"
    • In the case that thrombolytic is contraindicated, and the patient does not receive IV thrombolytic at this hospital, select "No" for IV alteplase initiated at this hospital and select "Yes" for Documented Contraindications or Warnings for not initiating IV thrombolytic in either the 0-3 hour or 3-4.5 hour treatment window. Please note the previous use of the NC choice has been replaced by separate Yes/No questions for documented contraindications and warnings.
    • It is essential that documented contraindications or warnings for non-treatment be selected when applicable for both the 0-3 and the 3-4.5 hour windows since the actual contraindications and warnings may differ between the two windows.
    • Do not include thrombolytic therapy for indications other than ischemic stroke. That is, do not include intra-cerebral venous infusion for cerebral venous thrombosis, intraventricular infusion for intraventricular hemorrhage, intraparenchymal infusion for percutaneous aspiration of intracerebral hematoma, myocardial infarction, PE, or peripheral clot.
    • Currently, alteplase is the only FDA-approved IV thrombolytic.
    • Note: IV alteplase is not FDA approved for use in the 3-4.5 hour window, but there is a Class 1A level guideline from the AHA regarding this treatment. There is a Quality report available to assist tracking performance on this measure.
    • Expansion of the Time Window for Treatment of Acute Ischemic Stroke With Intravenous Tissue Plasminogen Activator: http://stroke.ahajournals.org/cgi/reprint/STROKEAHA.109.192535
      • Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, et al. AHA/ASA Guideline: Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;STR.0b013e318284056apublished online before print January 31 2013, doi:10.1161/STR.0b013e318284056a

    Suggested Data Sources:

    • Emergency Room Records
    • Medication Records
    • Progress Notes
    • IV Flow Sheets

    Additional Notes / Guidelines for Abstraction:

    • Inclusion:
      • Only Acceptable Thrombolytic Therapy for Stroke
        • Activase
        • Alteplase
        • IV tPA
        • Recombinant tPA Tissue Plasminogen Activator
        • tPA Tissue Plasminogen Activator
      • Reasonable Alternative to Alteplase:
        • Tenecteplase
        • TNK
        • TNKase
    • Exclusion:
      • Intra-arterial (IA) tPA
      • Thrombolytic administration to flush, open, or maintain patency of a central link, e.g. PICC line.
      • Thrombolytic agents other than alteplase or tenecteplase

    Summary of Changes

    REQUIRED: Date/Time IV alteplase initiated (at this hospital or ED)

    If IV alteplase was initiated at this hospital or ED, record the date and time that IV alteplase was initiated (time of bolus administration). If there are discrepancies in the documentation of bolus administration, the nursing documentation on the medication administration sheets or hospital approved electronic system should be treated as the most reliable source, followed by the stroke physician's documented time or ED note. If multiple dates/times are documented by the same individual, use the earliest date recorded by that person.

    Please note, this time of treatment is used to control skip logic related to contraindications, warnings, etc related to non-treatment, so it is critical to enter the correct date/time here. If the data elements are not appearing as expected, please check that the date/time is abstracted accurately.

    • Date:MM/DD/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    Notes for Abstraction:

    • This data element applies only to patients for whom IV thrombolytic therapy was initiated at this hospital. Do not abstract this data element if IV thrombolytic therapy was initiated at another hospital and patient was subsequently transferred to this hospital.
    • IV alteplase is the only FDA-approved IV thrombolytic therapy.

    Example: For Patient 170a, the nursing documentation indicates that a bolus of IV alteplase occurred at 1300 and that there was a 10 minute delay in finding an infusion pump, so infusion started at 1310. Record the Date and Time of IV alteplase Initiated as 1300.

    Emergency department record, IV flow sheets, Medication administration record, Nursing flow sheets, Progress notes

    Thrombolytic Used

    Collected For: GWTG

    Definition: Documentation of the type of thrombolytic used.

    Question: Which thrombolytic was used at this hospital?

    Format: Single Select, Text Field, Check Box

    Allowable Values:

    • Alteplase (Class Evidence)
      • Total Dose (mg): Text Field
      • Alteplase Dose ND
    • Tenecteplase (Class 2b Evidence)
      • Total Dose (mg): Text Field
      • Tenecteplase Dose ND

    Notes for Abstraction:

    • Select the thrombolytic (Alteplase or Tenecteplase) that was administered to the patient at your hospital.
    • Once thrombolytic is selected, enter the total dose ordered, in milligrams, as it is recorded in the medical record.
      • For alteplase, total dose includes bolus and infusion
      • For Tenecteplase, total dose is the bolus
    • If the dose is not documented in the medical record, then select "Dose ND".
    • This data element applies only to patients for whom IV thrombolytic therapy was initiated at this hospital. Do not abstract this data element if IV thrombolytic therapy was initiated at another hospital and patient was subsequently transferred to this hospital.

    Suggested Data Sources:

    • Hospitalization Data

    Additional Notes / Guidelines for Abstraction: N/A

    Reason for Selecting Tenecteplaste Instead of Alteplase

    Collected For: GWTG

    Definition: Documentation of the reason Tenecteplase was used instead of Alteplase

    Question: What was the reason for selecting Tenecteplase instead of alteplase?

    Format: Single Select

    Allowable Values:

    • Large Vessel Occlusion (LVO) with potential thrombectomy
    • Mild Stroke
    • Other: ____________________

    Notes for Abstraction:

    • Thrombectomy or Endovascular Therapy (EVT) is an advanced neurological procedure for removal of a cerebral occlusion using a mechanical device, also known as a clot retrieval device or stent retriever, and/or aspiration technique.
    • Large Vessel Occlusion (LVO) with potential thrombectomy should be documented by a physician/APN/PA or pharmacist as the reason why Tenecteplase was chosen instead of alteplase.
    • If tenecteplase was administered prior to potential mechanical thrombectomy, then select "Large Vessel Occlusion (LVO) with potential thrombectomy".
    • Documentation can include:
      • Suspicious for left MCA - CT head negative for ICH - will transfer for potential LVO thrombectomy.
      • CTA abnormal, right MCA proximal M2 superior occlusion - transfer with possible neuro-intervention.
      • CT positive for LVO-transfer recommended because of the need for vascular surgical intervention.
      • Patient being transferred for potential intravascular clot removal.
      • Transfer to interventional suite.
      • Patient will be transferred for further management of stroke-like symptoms with possible acute large vessel occlusion.
      • Unacceptable example (select "No"):
      • Although the patient is being transferred to a higher level of care due to complete occlusion, it is mostly likely that thrombectomy will not be performed.
    • Stroke severity (mild stroke) should be documented by a physician/APN/PA or pharmacist as the reason why Tenecteplase was chosen instead of alteplase.
      • If the physician documents "Tenecteplaste used due to low NIHSS" then this would appropriately be categorized as mild stroke.
    • Select "Other" if the reason for choosing Tenecteplase instead of alteplase is a reason other than "Large Vessel Occlusion (LVO) with potential thrombectomy" and "Mild Stroke", or is not documented in the medical record.
    • When selecting "Other" type in the specific reason for choosing Tenecteplase if available in the medical record.

    Suggested Data Sources:

    • Admission Data
    • Hospitalization Data

    Additional Notes / Guidelines for Abstraction: N/A

    If IV Thrombolytic administered beyond 4.5 hours, was imaging used to identify eligibility?

    Collected For: GWTG

    Definition: Documentation that imaging was used to determine thrombolytic eligibility

    Question: If IV Thrombolytic was administered beyond 4.5 hours, was imaging used to identify the patient's eligibility?

    Format: Single Select

    Allowable Values:

    • Yes, Diffusion-FLAIR mismatch
    • Yes, Core-Perfusion Mismatch
    • None
    • Other: ____________________

    Notes for Abstraction:

    • Diffusion flair mismatch is documented in the record or the presents of a diffusion hyperintensity without a corresponding flair hyperintensity on brain MRI.
    • Mismatch between the perfusion and the core may be visualized on CT perfusion or MRI perfusion studies. This mismatch may also be termed "penumbra".

    Suggested Data Sources:

    • Admission Data
    • Hospitalization Data

    Additional Notes / Guidelines for Abstraction: N/A

    REQUIRED FOR COMPREHENSIVE: Date/Time IV alteplase initiated

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: IV Thrombolytic Initiation Date/Time

    Collected For: CSTK-05

    Definition: The month, date, year, and time (military time) that IV thrombolytic therapy was initiated to a patient with ischemic stroke at this hospital. IV thrombolytics convert plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving thrombus.

    Suggested Data Collection Question: What is the date and time that IV thrombolytic therapy was initiated for this patient at this hospital?

    Format

    Length:
    10 - MM-DD-YYYY (includes dashes) or UTD, 5 - HH-MM (with or without colon) or UTD
    Type: Date/Time
    Occurs: 1

    Allowable Values:

    MM = Month (01-12)
    DD = Day (01-31)
    YYYY = Year (2001-Current Year)
    UTD = Unable to Determine

    HH = Hour (00-23)
    MM = Minutes (00-59)
    UTD = Unable to Determine

    Notes for Abstraction:

    • Use the date at which initiation of the IV thrombolytic was first documented. If a discrepancy exists in date documentation from different sources, choose the earliest date. If there are two or more different IV thrombolytic initiation dates (either different IV thrombolytic episodes or corresponding with the same episode), enter the earliest date.
    • If the date IV thrombolytic therapy was initiated is unable to be determined from medical record documentation, select UTD.
    • The medical record must be abstracted as documented (taken at face value). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD.
      Example:
      Documentation indicates the IV thrombolytic initiation date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the IV thrombolytic initiation date is outside of the range listed in the Allowable Values for Day, it is not a valid date and the abstractor should select UTD.
      Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commissions Data Warehouse. Use of UTD for IV Thrombolytic Initiation Date allows the case to be accepted into the warehouse
    • Use the time at which initiation of the IV thrombolytic was first documented. If a discrepancy exists in time documentation from different sources, choose the earliest time. If there are two or more different IV thrombolytic initiation times (either different IV thrombolytic episodes or corresponding with the same episode), enter the earliest time.
    • For times that include seconds, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00
    • The use of hang time or infusion time is acceptable as IV thrombolytic initiation time when other documentation cannot be found.
    • IV thrombolytic initiation time refers to the time the thrombolytic bolus/infusion was started.
    • Do not use physician orders as they do not demonstrate initiation of the IV thrombolytic (in the ED this may be used if signed/initialed by a nurse).
    • If the time of IV thrombolytic initiation is unable to be determined from medical record documentation, select UTD.
    • The medical record must be abstracted as documented (taken at face value). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select UTD.
      Example:
      Documentation indicates the IV thrombolytic initiation time was 3300. No other documentation in the medical record provides a valid time. Since the IV thrombolytic initiation time is outside of the range listed in the Allowable Values for Hour, it is not a valid time and the abstractor should select UTD.
      Note: Transmission of a case with an invalid time as described above will be rejected from the Joint Commissions Data Warehouse. Use of UTD for IV Thrombolytic Initiation Time allows the case to be accepted into the warehouse.

    Suggested Data Sources:

    • Emergency department record
    • Nursing flow sheet
    • Progress notes
    • IV flow sheets
    • Medication administration record

    Guidelines for Abstraction

    Inclusion: None

    Exclusion: None

    Summary of Changes

    REQUIRED: Documented Contraindications or Warnings for not initiating IV thrombolytic in the 0-3hr treatment window?

    • Yes: There is a documented contraindication or warning for not initiating IV alteplase in the 0 - 3 hour treatment window.
    • No: There are no specific reasons documented in the medical record why IV alteplase was not administered or a hospital-related factor or other reason was present which may or may not be documented but was apparent to the abstractor. This (hospital-related factor or other reason) is the only section where it may be proper to infer reasons for non-treatment and is provided to assist in quality improvement activities.

    It is not expected that in routine situations the physician will explicitly identify which contraindications or warnings were relevant to the 0-3 or 3-4.5 hour window. Most likely, this will only be documented when different reasons were relevant to the decision for the two time windows.

    See examples under Documented Reasons in the medical record for no IV alteplase started at your hospital.

    Notes for Abstraction:

    • In order to select “Yes,” reasons for not initiating IV thrombolytic therapy must be documented by a physician/APN/PA and mentioned in the context of IV thrombolytics and fall on the Exclusion Criteria (contraindications) and/or Relative Exclusion Criteria (warnings).
    • Patient/family refusal, NIHSS score of zero, and initiation of IV or IA thrombolytic at a transferring hospital may be documented by a nurse.
    • If the reason documented for non-treatment with IV thrombolytics does not fall into one of the response options on the Exclusion Criteria(0-3hr) or Relative Exclusion Criteria(0-3hr) lists below, select “No” here.
    • Documentation of the initiation of IV or IA thrombolytic at a transferring hospital is a stand-alone reason and sufficient to meet the intent of this data element. No further documentation of it as the reason for not initiating IV alteplase at this hospital is needed in order to select “Yes” here.
    • If documentation indicates a National Institute of Health Stroke Scale (NIHSS) score of zero, select “Yes” to Documented Contraindications or Warnings for not initiating IV thrombolytic and choose Relative Exclusion Criteria “Stroke severity too mild” under Warnings . Score documentation must refer to the timeframe for thrombolytic therapy.
    • For additional clarity, see examples under Documented Reasons in the medical record for no IV alteplase started at your hospital.
    • Specifications Manual for National Hospital Inpatient Quality Measures note for TJC/CM users: The data element of documented reasons for not initiating IV thrombolytic on the Core Measures tab allows for inclusion of alternate reasons documented by physician/APN/PA or pharmacist beyond those listed on the Exclusions Criteria and Relative Exclusion Criteria lists below as long as the reasons are mentioned in the context of IV thrombolytics. If there is documentation in the medical record of an alternate reason for not initiating IV thrombolytic (e.g. a reason that is not on the Exclusion Criteria and/or Relative Exclusion Criteria lists below) and that reason is linked to IV thrombolytics you may need to adjust the auto-populated response on the Core Measures tab. To do so, just click into that tab to view the exact definition from the Specifications Manual for National Hospital Inpatient Quality Measures and adjust your response if appropriate.

    Examples:

    • Ischemic stroke patient has a history of seizures and is taking an anti-convulsants. The family states that the patient had twitching of his arm before he became aphasic. The doctor documents the possibility of seizure with residual neurological symptoms as the reason for non-treatment with IV alteplase. Select “Yes” for Documented Contraindications or Warnings for not initiating IV thrombolytic in the 0-3hr treatment window. Also select Exclusion Criteria "Seizure at onset" (0-3hr treatment window).
    • Patient with history of metastatic breast cancer and a life expectancy of nine months presents with an ischemic stroke one hour after last known well. Documentation never mentions IV thrombolytic therapy. Select “No” for Documented Contraindications or Warnings for not initiating IV thrombolytic in the 0-3hr treatment window?. The reason for non-treatment was never documented in the context of IV thrombolytics in this case. As the abstractor may have inferred that the reason for non-treatment was due to the patient’s co-morbid condition and limited life expectancy, you may select “Other” under Hospital-Related or Other Factors (0-3hr treatment window) and specify the reason for non-treatment there.
    • Patient presents with a headache that has persisted for 1 hour and 45 minutes. The patient is seen by an ED physician who believes that the patient has a migraine. The patient is seen by a neurologist several hours later, and after further work-up, is determined to have an ischemic stroke. Medical record documentation by the neurologist states “patient was not a candidate for IV alteplase, as by the time he was diagnosed with an ischemic stroke, 8 hours had passed since he was last known to be well.” Select Documented Contraindications or Warnings for not initiating IV thrombolytic in the 0-3hr treatment window = “No.” Although there is documentation around thrombolytic therapy in the record, the reason for non-treatment does not fall on the Exclusion Criteria or Relative Exclusion Criteria lists. In this case, the abstractor should select Hospital-Related or Other Factors (0-3hr treatment window) = “Delay in Stroke Diagnosis.”

    OPTIONAL: Documented Contraindications or Warnings for not initiating IV thrombolytic in the 3-4.5hr treatment window?

    • Yes: There is a documented contraindication or warning for not initiating IV alteplase in the 3 - 4.5 hour treatment window.
    • No: There are no specific reasons documented in the medical record why IV alteplase was not administered or if a hospital-related factor or other reason was present which may or may not be documented but was apparent to the abstractor. This (hospital-related factor or other reason) is the only section where it may be proper to infer reasons for non-treatment and is provided to assist in quality improvement activities.

    It is not expected that in routine situations the physician will explicitly identify which contraindications or warnings were relevant to the 0-3 or 3-4.5 hour window. Most likely, this will only be documented when different reasons were relevant to the decision for the two time windows.

    Notes for Abstraction:

    • In order to select “Yes,” reasons for not initiating IV thrombolytic therapy must be documented by a physician/APN/PA and mentioned in the context of IV thrombolytics and fall on the Exclusion Criteria and/or Relative Exclusion Criteria lists below.
    • Patient/family refusal, NIHSS score of zero, and initiation of IV or IA thrombolytic at a transferring hospital may be documented by a nurse.
    • If the reason documented for non-treatment with IV thrombolytics does not fall into one of the response options on the Exclusion Crtieria (3-4.5hr) or Relative Exclusion Criteria (3-4.5) lists below, select “No” here.
    • Documentation of the initiation of IV or IA thrombolytic at a transferring hospital is a stand-alone reason and sufficient to meet the intent of this data element. No further documentation of it as the reason for not initiating IV alteplase at this hospital is needed in order to select “Yes” here.
    • If documentation indicates a National Institute of Health Stroke Scale (NIHSS) score of zero, select “Yes” to Documented Contraindications or Warnings for not initiating IV thrombolytic and choose “Stroke severity too mild” under Relative Exclusion Criteria. Score documentation must refer to the timeframe for thrombolytic therapy.
    • For additional clarity, see examples under Documented Reasons in the medical record for no IV alteplase started at your hospital.

    • Examples:

      • Ischemic stroke patient has a history of seizures and is taking an anti-convulsant. The family states that the patient had twitching of his arm before he became aphasic. The doctor documents the possibility of seizure with residual neurological symptoms as the reason for non-treatment with IV alteplase. Select “Yes” for Documented Contraindications or Warnings for not initiating IV thrombolytic in the 3-4.5hr treatment window. Also select Exclusion Criteria "Seizure at onset" (3-4.5hr treatment window).

    Admission Data, Hospitalization Data

    REQUIRED: Contraindications and/or Warnings (0-3 hr treatment window). Select all that apply.

    OPTIONAL: Contraindications and/or Warnings (3-4.5 hr treatment window). Select all that apply.

    Select the specific reason(s) documented in the medical record for not administering IV alteplase at this hospital.

    The following lists include contraindications and warnings which have been taken from the clinical practice guidelines. The reasons provided herein are not intended to supersede physician judgment, but serve as a guideline to abstractors. As always, the physician must exercise due caution in providing treatment, given the risks and benefits to the individual patient and the available information at the time of treatment decision. For further guidance on what kind of patients should or should not be treated with IV alteplase, refer to "2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professional From the American Heart Association/American Stroke Association.” See Table 6 for a listing of Characteristics of Patients with Ischemic Stroke Who Could Be Treated With alteplase within the 0 - 3 hour time window, taken from the Guidelines.

    Exclusion Criteria (contraindications) (0-3 hr and 3-4.5 hr treatment windows):

    • Elevated blood pressure (systolic > 185 mm Hg or diastolic > 110 mm Hg) despite treatment
    • Recent intracranial or spinal surgery or significant head trauma, or prior stroke in previous 3 months
    • History of previous intracranial hemorrhage, intracranial neoplasm, arteriovenous malformation, or aneurysm
    • Active internal bleeding
    • Acute bleeding diathesis (low platelet count, increased PTT, INR ≥ 1.7 or use of NOAC). This includes: Platelet count <100 000/mm3; Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than the limit or normal; current use of anticoagulant with INR >1.7 or PT >15 seconds; current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet ocunt, and ECT; TT; or appropriate factor Xa activity assays)
    • Symptoms suggest subarachnoid hemorrhage
    • CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
    • Arterial puncture at noncompressible site in previous 7 days
    • Blood glucose concentration <50 mg/dL (2.7 mmol/L)

    Relative Exclusion Criteria (warnings) (0-3 hr and 3-4.5 hr treatment windows):

    Recent experience suggests that under some circumstances- with careful consideration and weighting of risk to benefit- patients may receive fibrinolytic therapy despite 1 or more relative contraindications. Consider risk to benefit of IV alteplase administration carefully if any of these relative exclusion criteria are present:

    • Care-team unable to determine eligibility
    • IV or IA thrombolysis/thrombectomy at an outside hospital prior to arrival
    • Life expectancy < 1 year or severe co-morbid illness or CMO on admission
    • Pregnancy
    • Patient/Family refusal
    • Stroke severity too mild (non-disabling)
    • Recent acute myocardial infarction (within previous 3 months)
    • Seizure at onset with postictal residual neurological impairments
    • Major surgery or serious trauma withinin previous 14 days
    • Recent gastroinestinal or urinary tract hemorrhage (within previous 21 days)

    Notes for Abstraction:

    • Reasons for not initiating IV thrombolytic therapy must be documented by a physician/APN/PA or pharmacist with three exceptions: Patient/family refusal, NIHSS score of zero, and initiation of IV or IA thrombolytic at a transferring hospital. These three exceptions may be documented by a nurse. Reason documentation must refer to the timeframe for thrombolytic therapy.
    • Exclusions and/or relative exclusions (contraindications and/or warnings) must be mentioned in the context of IV thrombolytics. It is the intent that the abstractor will not make inference as to the reason for non-treatment based upon the presence of certain patient clinical characteristics and conditions in the record, but will only abstract reasons that are specifically documented in the medical record as the reason for not giving thrombolytic therapy. If reasons are not mentioned in the context of IV thrombolytics, do not make inferences (e.g., do not assume that IV thrombolytic was not initiated because of a bleeding disorder unless documentation explicitly states so.)
    • Documentation of the initiation of IV or IA thrombolytic at a transferring hospital is a stand-alone reason and sufficient to meet the intent of this data element. No further documentation of it as the reason for not initiating IV alteplase at this hospital is needed.
    • If documentation indicates a National Institute of Health Stroke Scale (NIHSS) score of zero, select “Yes” to Documented Contraindications or Warnings for not initiating IV thrombolytic and choose “Stroke severity too mild (non-disabling)” here . Score documentation must refer to the timeframe for thrombolytic therapy.
    • It is not acceptable to use documentation from outside physician or nurse notes that played a factor in the decision-making process for not giving thrombolytic therapy. EXCEPTION: If your hospital uses telemedicine in assessing stroke patients, it is acceptable to select reasons specified by the teleneurologist when reasons are documented in the medical record. In these cases, it is acceptable for the documentation to be done by a nurse.
    • It is permissible to abstract reasons for non-treatment from the medical record that are documented after the IV alteplase treatment decision has been made as long as the documentation is made prior to patient discharge (addendums cannot be made after discharge). Documented reason must refer to the timeframe for thrombolytic therapy.   Suggested data sources: consultation notes, ED records, H&P, MAR, progress notes (exclusion: discharge summary).
    • It is essential that documented reasons for non-treatment be selected for both the 0-3 and the 3-4.5 hour treatment windows when applicable since the reasons may differ between the two windows. Due to the dynamic nature of acute stroke symptoms and patient response to interventions (e.g. blood pressure control), patients who are not eligible for treatment in the first three hours may become eligible in the later window and should still be considered for treatment. Click here to reference the new guideline update from the American Heart Association/American Stroke Association regarding the Expansion of the Time Window for Treatment of Acute Ischemic Stroke With Intravenous Tissue Plasminogen Activator. (link is http://stroke.ahajournals.org/cgi/reprint/STROKEAHA.109.192535 )
          • It is not expected that in routine situations the physician will explicitly identify which contraindication(s) and/or warning(s) were relevant to the 0-3 or 3-4.5 hour window. Most likely, this will only be documented when different reasons were relevant to the decision for the two time windows. If contraindication(s) and/or warning(s) for non-treatment are documented for the 0-3 hour treatment window, it is acceptable to assume the same reason(s) for non-treatment to be valid for the 3-4.5 hour window unless documentation in the medical record indicates the patients clinical condition changed. (e.g. If SBP > 185 or DBP > 110 mmHg, Stroke Severity too mild, Stroke Severity too severe, Rapid improvement, or Care Team Unable to determine eligibility are documented as the reason(s) for not administering IV alteplase in the 0-3 hour time window, and there is documentation of a change in clinical status within 4.5 hours in the medical record then you should not assume that the same reason for non-treatment remains in the extended time window. In these situations, there must be specific documentation around the reason for non-treatment in the 3-4.5 hour window.

    Examples:

    • An ischemic stroke patient presents within 2 hours of Last Known Well with SBP of 220. Physician documents “no alteplase due to elevated Blood Pressure.” With treatment, the patient’s SBP is brought down to 150 at 3.5 hours after Last Known Well but there is no additional documentation in the medical record with regards to thrombolytic treatment. Select “Yes” to “Documented Contraindications or warnings for not initiating IV thrombolytic in the 0-3hr treatment window” and then choose “C1: SBP> 185 or DBP > 110 mmHg despite treatment.” Select “No” to “Documented Contraindications or warnings for not initiating IV thrombolytic in the 3-4.5hr treatment window.”
    • An ischemic stroke patient presents within 2 hours of Last Known Well with an NIHSS of 29. Physician documents “no alteplase due to elevated NIHSS.” There's documentation in the medical record of an NIHSS=26 at 3.5 hours after Last Known Well and the physician documents that the patient is not a candidate for alteplase in the extended time window due to NIHSS>25. Select “No” to “Documented Contraindications or warnings for not initiating IV thrombolytic in the 0-3hr treatment window”. There is no stroke severity limit or NIHSS limit for treatment in the 0-3 hour window. Select “Yes” to “Documented Contraindications or warnings for not initiating IV thrombolytic in the 3-4.5hr treatment window” and then choose “AW4: Severe Stroke Severity NIHSS >25”
    • An ischemic stroke patient presents with an unclear onset time. Physician documents “timing of stroke symptom onset is unclear therefore no alteplase at this time”. One hour later the patient’s daughter arrives and states that her father was well 3 hours prior and had no stroke symptoms. There is no further documentation in the medical record around alteplase. Select “Yes” to “Documented Contraindications or warnings for not initiating IV thrombolytic in the 0-3hr treatment window” and then choose Exclusion Criteria “Care team unable to determine eligibility” (0-3 hr treatment window). Select “No” to “Documented Contraindications or warnings for not initiating IV thrombolytic in the 3-4.5hr treatment window.

    The following should help abstractors in classifying reasons:

    • If the patient is on anticoagulants (Warfarin, Coumadin) and this is documented as the reason for not administering IV thrombolytics, and the PT, PTT, or INR is elevated, select Exclusion Criteria “Acute bleeding diathesis. Use of anticoagulants without reference to INR is an Additional Exclusion Criteria for the 3-4.5 treatment window – “ Taking oral anticoagulants regardless of INR”.
    • Conditions that increase the risk of bleeding or decrease the benefit of treatment to the individual patient must be explicitly listed in the medical record and documented as being the reason that thrombolytics were not used. Conditions may include: Acute pericarditis, SBE (spontaneous bacterial endocarditis), Hemostatic defects, Diabetic hemorrhagic retinopathy, Septic thrombophlebitis, occluded AV cannula, or patient is currently receiving oral anticoagulants (e.g., Warfarin, therapeutic dose of dabigatran (Pradaxa).
    • Advanced age alone is no longer considered a sufficient reason for not providing alteplase in the 0-3 hour window. There is sufficient evidence from subgroup analysis of the randomized trials to conclude that beneficial effects of alteplase are seen in advanced age when patients are treated with 0-3 hours, and the Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acue Ischemic Stroke: A Statement for Healthcare Professionals from the American Heart Association/American Stroke Association recommends treatment of elderly ischemic stroke patients who meet other criteria, without restriction by age. There is no specific upper age limit on the use of IV alteplase. However, the prevalence of other exclusions or relative exclusions to treatment (e.g. other illnesses that reduce life expectancy to <1 year) may be higher in patients with very advanced age, reducing the number of elderly patients who may be eligible for alteplase treatment. For patients at 3-4.5 hours, age >80 remains a relative exclusion because such patients were not included in the randomized controlled trial.
    • "Care-team unable to determine eligibility" means that the diagnosis of stroke was made but that eligibility for thrombolytic therapy could not be established or verified by the clinician. Examples may include:
      • The time of onset could not be clearly established at the time of patient assessment in the ED or time of Last Known Well is unknown
      • Timing of a recent procedure or surgery could not be definitively established.
      • A lack of an accurate history or concern about the presence of a preexisting medical condition raises concern about eligibility for IV thrombolytic therapy.
      • Patients who have experienced multiple episodes of transient neurologic function, or TIAs, which have fully resolved clinically, but imaging or other features of the history make it uncertain as to when the stroke actually started.
    • Select "IV or IA alteplase given at outside hospital" when a patient was transferred from another hospital where IV alteplase was started, even if the infusion continues after the patient arrives at your facility. Explicit documentation stating that "further alteplase is not required" is not necessary. It would be acceptable for this to be documented by a nurse.
    • Select "Life expectancy < 1 year or severe co-morbid illness or CMO on admission" if the patient has an order for Comfort Measures Only in the ED and this restriction of care preceded evaluation for IV alteplase. This option is also appropriate when patients are not treated due to coexisting terminal cancer, advanced dementia, severe cardiopulmonary disease or other conditions which severely limit quality of life or life expectancy. Limited life expectancy, severe co-morbid conditions, and CMO status all need to be explicitly documented as the reason for no IV Do not make inferences.
    • If the physician documents that the patient declines IV alteplase in favor of catheter-based reperfusion or other investigational therapy, select "Pt./Family refused"
    • Select "Stroke severity too mild (non-disabling) when there is minimal to no disability associated with the stroke symptoms (e.g. numbness, mild weakness, lack of gait impairment). Note that there is no lower limit to NIHSS score that prohibits the use of IV alteplase.
    • If the physician documents "no IV alteplase due to low NIHSS or NIHSS = 3," then this would appropriately be categorized as stroke severity too mild.
    • If documentation indicates an NIHSS score of zero, then this may be considered the equivalent of documentation that the stroke was too mild, and an explicit statement linking this as the reason for non-treatment is not required.
    • Select "Severe Stroke NIHSS >25" when the physician notes document “alteplase was withheld due to the severity of the stroke symptoms". Note there is no upper limit in terms of NIHSS score that prohibits the use of IV alteplase and many centers would still treat a patient with an NIHSS score of 25. Severe stroke is not an exclusion or relative exclusion to treatment at 0-3 hours.
    • For inpatient stroke, the 0-3 and 3-4.5 hour treatment window is calculated from Symptom Discovery Date/Time -Date/Time Last Known Well.

    Examples:

    • Patient 180a has a history of seizures and is taking anti-convulsant, and the family states that he had twitching of his arm before he became aphasic. The doctor documents the possibility of 'seizure with residual neurological symptoms' as the reason for non-treatment with IV alteplase. Select "Seizure at onset with postictal residual neurological symptoms" as Exclusion Criteria in both 0-3 and 3-4.5 hour treatment window. (Note, the abstractor should also select "No" for " IV alteplase initiated at this hospital" and "Yes" for "Documented Contraindications and Warnings for not initiating IV alteplase" for both 0-3 and 3-4.5 hour treatment windows.)
    • Patient 180b is a 95 year old male who presents with aphasia and right-sided weakness. He is not treated with IV alteplase and the reason is documented as "increased risk of bleeding due to advanced age". Select "No" for "IV alteplase initiated at this hospital"; "No" for "Documented Contraindications and Warnings for not initiating IV alteplase" in the 0-3 hour window; "Yes" for "Documented Contraindications and Warnings for not initiating IV alteplase" in the 3-4.5 hour window; and select "Age>80" for Additional Relative Exclusion Criteria 3- 4.5 hour window.
    • Patient 180b is a 95 year old male who presents with aphasia and right-sided weakness. He was last seen well 2 hours ago. He was referred from a long term care facility, where he was residing because of advanced dementia. He is not treated with IV alteplase and the reason is document as “Not given alteplase—too old”. Select "No" for "IV alteplase initiated at this hospital" ; "No" for "Documented Contraindications and Warnings for not initiating IV alteplase" in the 0-3 hour window; “Yes for "Documented Contraindications and Warnings for not initiating IV alteplase" in the 3-4.5 hour window; and Select "Age > 80" for Additional Relative Exclusion Criteria3-4.5 hour window. In this case the patient’s age (95) is a relative exclusion for initiating IV alteplase in the 3-4.5 hour window, but not in the 0-3 hour window. Therefore the abstractor must indicate "No" for "Documented Contraindications and Warnings for not initiating IV alteplase" in the 0-3 hour window. The abstractor might guess that treatment was not offered at 0-3 hours because of dementia, a severe co-morbid illness; however, inferences are not allowed. If the clinician had instead documented “No tPA—advanced dementia” then the abstractor could have documented “Yes” to “Documented Contraindications and Warnings for not initiating IV alteplase A" and selected “Life expectancy < 1 year or severe co-morbid illness or CMO on admission”.
  • Patient 180c came into the ED within 120 minutes of time last known well.  After a head CT, the ED physician recommended to the patient's wife that the patient receive IV-alteplase.  The wife wanted to wait to discuss the issue with the daughter, who was driving to the hospital.  The physician documented in the medical record the wife’s refusal of treatment pending discussion with her daughter. When the daughter finally arrived, the patient was outside the 180 min window, and so IV-tPA was initiated in the 3-4.5 hour treatment window. Select "Pt./Family refused" under Warnings in the 0-3 hr treatment window. Note the abstractor would also select "Yes" for "IV alteplase initiated at this hospital “and "Yes" for "Documented Contraindications and Warnings for not initiating IV alteplase in the 0-3 hour time window". Note because the patient received treatment in the 3-4.5 hour, Contraindications and Warnings in the 3-4.5 hour treatment window will be disabled on the online form).
  • Patient 180d arrives at the ED at 1hr 50min after Last Known Well. The hospital acute stroke team is consulted and every effort is made to treat him within 3 hours of symptom onset, but the bolus is not started until 3hr 10min after Last Known Well. Because the patient did not receive IV alteplase within the first 3 hours and there is no contraindication and/or warning documented for non treatment in the 0-3 hour time window, do NOT select any contraindications or warnings in the 0-3 hour treatment window. Note the abstractor would also select “No” for “Documented contraindications or warnings in the 0-3 hour treatment window” and select the appropriate hospital-related factor that contributed to the delay if applicable. (Note because the patient received treatment in the 3-4.5 hour, Contraindications and Warnings in the 3-4.5 hour treatment window will be disabled on the online form).
  • Patient 180e arrives within 2 hours from Last Known Well. His NIHSS is 2, due to mild dysarthria and mild drift. The physician documents no IV alteplase due to mild stroke. However, at 3hr 15min after Last Known Well, he suddenly worsens to an NIHSS of 10. At this point, the physician reviews the results of his IV alteplase evaluation and finds no contraindications or warnings, including the additional warnings for patients beyond the 3 hour window. IV alteplase is administered at 3hr 50min after Last Known Well. Select “Stroke severity too mild (non-disabling)” under Warnings for the 0-3 hour treatment window. Note that the abstractor would also select “Yes” for “Documented contraindications or warnings in the 0-3 hour time window” (Note because the patient received treatment Contraindications and Warning in the 3-4.5 hour treatment window will be disabled on the online form..
  • Patient 180f is brought to the ED by his daughter who found him aphasic at home at 4pm. She had last seen him well at 8am that morning. The physician documents no IV alteplase due to greater than 4.5 hours since Last Known Well. While the patient is still in the ED, the son who lives at home arrives at 4:30pm and states that he saw his father well at 2:15pm. In light of this new information, the patient is rapidly evaluated and receives IV alteplase at 6pm, 3.75 hours after the new Last Known Well time of 2:15 pm. At the time of his initial evaluation, the care team was unable to determine if he was eligible due to the long interval from Last Known Well. Select "Care-team unable to determine eligibility" under Warnings for the 0-3 hour treatment window. . If there was no physician documentation describing this change in the time Last Known Well, do not infer that this was the cause of non-treatment in the 0-3 hour treatment window. Note the abstractor should also select “Yes” for “Documented contraindications or warnings for not initiating IV alteplase in the 0-3 hour treatment window”
  • Admission Data, Hospitalization Data

    Summary of Changes

    OPTIONAL: Additional Warnings 3-4.5 hrs. Select all that apply.

    Select the specific reason(s) documented in the medical record for not administering IV alteplase at this hospital for patients considered for treatment with IV alteplase in the 3-4.5 hour treatment window.

    • Age > 80
    • History of both diabetes and prior ischemic stroke
    • Taking an oral anticoagulan regardless of INR
    • Severe stroke (NIHSS > 25)

    Notes for Abstraction:

    • Only select “Additional Warnings” if any of these reasons for no IV alteplase are explicitly documented in the context of the 3-4.5 hour treatment window. (i.e. the physician documented “no IV alteplase after 3 hours of symptom onset due to NIHSS= 27”, Select “NIHSS>25”.

    Examples:

    • Patient 181a arrives at 1 hour and 50 minutes after Last Known Well, with an NIH stroke scale of 10 and he takes warfarin for atrial fibrillation. His blood pressure is 190/105 and he requires several doses of labetalol to control his blood pressure. By the time it is under control, it is 3hrs 10min after Last Known Well. His INR is 1.3. He does not receive IV alteplase. The physician documents that he was not eligible for IV alteplase when he arrived due to uncontrolled blood pressure and that the use of warfarin made him ineligible for treatment beyond 3 hours. Select “SBP > 185 or DBP > 110 mmHg despite treatment” under “Contraindications 0-3 hr window”, select “Increased risk of bleeding due to comorbid conditions” under “Warnings 3-4.5 hr window” and select “Any anticoagulant use prior to admission (even if INR < 1.7)” under “Additional Warnings 3-4.5 hr window”.

    OPTIONAL: Hospital-related or Other Factors (0-3 hr and 3-4.5 hr treatment windows). Select all that apply

    Select the reason(s) for not administering IV alteplase that are present in the medical record which may or may not be documented but are apparent to the abstractor as reasons for non-treatment. This is the only section where it may be proper to infer reasons for non-treatment and is provided to assist in quality improvement activities. Selection of one or more of these reasons does NOT exclude patients from the denominator of the IV alteplase measures. Failure to complete the work up within the 3 hour treatment window or failure to diagnose ischemic stroke are not valid reasons to not give thrombolytic therapy.

    0-3 hr treatment window:

    • Delay in Patient Arrival
    • Delay in Stroke diagnosis
    • In-hospital Time Delay
    • No IV access
    • Rapid or Early Improvement
    • Advanced Age
    • Stroke to severe
    • Other

    3-4.5 hr treatment window:

    • Delay in Patient Arrival
    • Delay in Stroke diagnosis
    • In-hospital Time Delay
    • No IV access
    • Rapid or Early Improvement
    • Advanced Age
    • Stroke to severe
    • Other

    Notes for Abstraction:

    • If "Documented Contraindications or Warnings for not initiating IV thrombolytic?” is "No”, “Hospital-Related or Other Factors” can be selected. This is the ONLY section where it may be acceptable to infer reasons for non-treatment and is provided to assist in quality improvement activities.
    • If the diagnosis is unclear, select "Delay in Stroke diagnosis" under “Hospital-related or Other factors”. Note: The abstractor should also select "No" for “Documented Contraindications or Warnings for not initiating IV thrombolytic?”
    • If there is a delay in getting the CT done or read, or a delay in patient evaluation, then select "In-hospital Time Delay".
    • If patients receive IA therapy in favor of IV alteplase and there is no evidence documented in the medical record that the patient/family was offered IV alteplase, then select "Other" under “Hospital related or Other Factors”. Note the abstractor should also select "No" for “Documented Contraindications or Warnings for not initiating IV thrombolytic?”
    • Do not select "Other" if you have already selected a Contraindication or Warning. The choices under “Hospital Related and Other Factor for non-treatment” including "Other" will NOT exclude patients from the denominator of the IV alteplase measures.
    • Only use the "Other" field if there is no reason specified that can be accurately captured by the listed choices under Contraindications and Warnings. Be very certain that a reason does not logically fit into any of the listed categories before resorting to selecting “Other” and entering text in "Specify Other reason for non-treatment with IV thrombolytic". Review of the past data reveals that most of the reasons for not giving IV alteplase will fall into one of the above delineated categories.

    Example:

    • Patient 182a arrives at the ED at 1hr 50min after Last Known Well. The hospital acute stroke team is consulted and every effort is made to treat him within 3 hours of symptom onset, but the bolus is not started until 3hr 10min after Last Known Well. Upon chart review, the abstractor identified that the patient arrived to the hospital at 09:15 but the stroke team was not consulted until 09:45. Select “In-hospital Time Delay” under Hospital related or Other Factors for the 0-3 hour treatment window. Because the patient did not receive IV alteplase within the first 3 hours and there is no contraindication and/or warning documented for non-treatment in the 0-3 hour time window, DO NOT select any exclusion or relative exclusion criteria in the 0-3 hour treatment window.

    OPTIONAL: Specify Other Reason for no- IV thrombolytic(0-3 and 3-4.5 hr treatment windows).

    If "Other" is selected as the reason for non-treatment with IV thrombolytics under “Hospital Related or Other Factors”, specify the reason in the text box

    REQUIRED: (for patients that receive IV rt-PA beyond 60 minutes): If IV alteplase was initiated greater than 60 minutes after hospital arrival, were Eligibility or Medical reason(s) documented as the cause for delay:

    • Yes: There is a documented eligibility or medical reason for not initiating IV alteplase within 60 minutes of hospital arrival.
    • No: There are no specific documented eligibility or medical reasons in the medical record why alteplase was not administered within 60 minutes of hospital arrival, or, a hospital-related or other reason was present which may or may not be documented but was apparent to the abstractor. This is the only section where it may be proper to infer reasons for non-treatment and is provided to assist in quality improvement activities.

    REQUIRED: (for patients that receive IV rt-PA beyond 45 minutes): If IV alteplase was initiated greater than 45 minutes after hospital arrival, were Eligibility or Medical reason(s) documented as the cause for delay:

    • Yes: There is a documented eligibility or medical reason for not initiating IV alteplase within 45 minutes of hospital arrival.
    • No: There are no specific documented eligibility or medical reasons in the medical record why alteplase was not administered within 45 minutes of hospital arrival, or, a hospital-related or other reason was present which may or may not be documented but was apparent to the abstractor. This is the only section where it may be proper to infer reasons for non-treatment and is provided to assist in quality improvement activities.

    REQUIRED: (for patients that receive IV rt-PA beyond 30 minutes): If IV alteplase was initiated greater than 30 minutes after hospital arrival, were Eligibility or Medical reason(s) documented as the cause for delay:

    • Yes: There is a documented eligibility or medical reason for not initiating IV alteplase within 30 minutes of hospital arrival.
    • No: There are no specific documented eligibility or medical reasons in the medical record why alteplase was not administered within 30 minutes of hospital arrival, or, a hospital-related or other reason was present which may or may not be documented but was apparent to the abstractor. This is the only section where it may be proper to infer reasons for non-treatment and is provided to assist in quality improvement activities.

    Notes for Abstraction: (For 60, 45, and 30 minute reason for delay questions above)

    • Reasons for delay in treatment with IV thrombolytic therapy must be documented by a physician/APN/PA or pharmacist.
    • Eligibility and/or medical reasons for delay in treatment must be mentioned in the context of IV thrombolytics. It is the intent that the abstractor will not make inference as to the eligibility or medical reasons for delay in treatment based upon the presence of certain patient clinical characteristics and conditions in the record, but will only abstract reasons that are specifically documented in the medical record as the reason for the delay beyond 60 minutes.
    • Example: If the physician documents that the patient has uncontrolled hypertension and because of this alteplase cannot be administered until the patient’s blood pressure can be controlled with IV medications select the medical reason of “hypertension requiring aggressive control with IV medications.” Do not select this option simply because elevated blood pressure was described in the medical record.
    • If your hospital uses telemedicine in the assessment of stroke, and there is documentation in the medical record as to why the teleneurologist delayed treatment with IV alteplase, this is acceptable as documentation to select the eligibility and or medical reason(s) specified by the teleneurologist. In this case, it is acceptable for the documentation in your hospital’s medical record to be done by a nurse.
    • It is permissible to abstract reasons for non-treatment from the medical record that are entered after the IV alteplase treatment decision has occurred. This should be done only when the documentation is written by an appropriate provider who was involved in the IV alteplase decision, but was unable to document it at the time. This documentation needs to be made prior to patient discharge. For example the neurologist who was called by telephone puts a note in the medical record the next day which documents the reasons for delay.

    Select the specific reason(s) documented in the medical record for the delay in administration of IV alteplase at this hospital.

    Eligibility Reasons:

    • Social/Religious
    • Initial refusal
    • Care-team unable to determine eligibility
    • Specify eligibility reason: _______

    Medical Reasons:

    • Hypertension requiring aggressive control with IV medications
    • Further diagnostic evaluation to confirm stroke for patients with hypoglycemia (blood glucose < 50), seizures, or major metabolic disorders
    • Management of concomitant emergent/acute conditions such as cardiopulmonary arrest, respiratory failure (requiring intubation)
    • Investigational or experimental protocol for thrombolysis
    • Need for additional PPE for suspected/ confirmed infection disease
    • Specify medical reason: ________

    Notes for Abstraction:

    The following should help abstractors in classifying reasons:

    • Social/Religious means that the patient and/or family refused treatment due to their cultural or religious beliefs. As patients do have the right to change their treatment decisions, this choice should be selected if there is documentation that treatment with IV rt-PA was initially refused due to any social or religious reason. Example: Patient wishes to consult clergy prior to deciding whether or not he wishes to receive treatment. Clergy takes 30 minutes to arrive. After speaking with clergy, the patient decides to proceed with treatment with IV alteplase. Treatment is provided once the patient consents (now 75 minutes after arrival).
    • Initial refusal should be selected if there is documentation that the patient and/or family initially refused treatment with IV rt-PA for any reason other than a social/religious reason.
    • For patients that cannot participate in shared decision making or provide consent, select "Initial Refusal" if there is documentation that there was a delay in treatment with IV rt-PA due to reasonable attempts to contact a proxy decision maker to obtain consent.
    • "Care-team unable to determine eligibility" means that the diagnosis of stroke was made but that eligibility for thrombolytic therapy could not be established or verified by the clinician. Examples may include:
      • The time of onset could not be clearly established at the time of initial patient assessment in the ED or time of Last Known Well is unknown
      • Timing of a recent procedure or surgery could not be definitively established.
      • A lack of an accurate history or concern about the presence of a preexisting medical condition raises concern about eligibility for IV thrombolytic therapy.
      • Patients who have experienced multiple episodes of transient neurologic dysfunction, or TIAs, which have fully resolved clinically, but imaging or other features of the history make it uncertain as to when the stroke actually started.
    • Hypertension requiring aggressive control with IV medications: Select this option if there is documentation that treatment with intravenous IV rt-PA was delayed because aggressive measures (such as continuous infusion or the use of two or more intravenous antihypertensive agents) were first needed to reduce BP to a treatable range.
    • Further diagnostic evaluation to confirm stroke for patients with hypoglycemia (blood glucose < 50), seizures, or major metabolic disorders that were potentially stroke mimics
    • Management of concomitant emergent/acute conditions such as cardiopulmonary arrest, respiratory failure (requiring intubation)
    • Investigational or experimental protocol for thrombolysis: Documentation indicates that administration of IV rt-PA was delayed due to an investigational or experimental thrombolytic protocol. If investigational or experimental protocol was used, there should be a signed IRB consent in the medical record.
    • Need for additional PPE for suspected/ confirmed infectious disease: Select this option when there is documentation in the patient medical record that treatment was delayed so that health care providers could obtain additional Personal Protection Equipment (PPE) because the patient had a confirmed or suspected infection.

    Additional Notes / Guidelines for Abstraction: N/A

    If no documented eligibility or medical reason(s), Hospital Related or Other Reason(s):

    If a hospital-related or other reason was present which may or may not be documented but was apparent to the abstractor select the appropriate reason. This is the only section where it may be proper to infer reasons for non-treatment and is provided to assist in quality improvement activities.

    • Need for additional imaging
    • Delay in stroke diagnosis
    • In-hospital time delay
    • Equipment-related delay (e.g. telemedicine equipment issue, CAT Scan/MRI availability, IV pump malfunction)
    • Other: If Other is selected, specify other reason

    Was other thrombolytic/reperfusion therapy administered?

    IV Thrombolytic at an outside hospital or Mobile Stroke Unit

    Collected For: GWTG

    Definition: Documentation of prior IV thrombolytic administered at an outside hospital prior to transfer or in a mobile stroke unit.

    Question: Indicate if IV thrombolytic was initiated at an outside hospital.

    Format: Single Select

    Allowable Values:

    • Yes
    • No

    Notes for Abstraction:

    • Select “Yes" when a patient was transferred from another hospital where IV thrombolytic was started, even if the infusion continues after the patient arrives at your facility.

    Suggested Data Sources:

    • Admission Data
    • Hospitalization Data

    Additional Notes / Guidelines for Abstraction: N/A

    If yes, select thrombolytic administered at outside hospital or Mobile Stroke Unit

    Collected For: GWTG

    Definition: Documentation of the type of thrombolytic administered at outside hospital or Mobile Stroke Unit

    Question: If yes, thrombolytic was administered at an outside hospital or Mobile Stroke Unit, which thrombolytic was administered?

    Format: Single Select

    Allowable Values:

    • Alteplase
    • Tenecteplase

    Notes for Abstraction: N/A

    Suggested Data Sources:

    • Admission Data
    • Hospitalization Data

    Additional Notes / Guidelines for Abstraction: N/A


    Endovascular Therapy

    REQUIRED FOR TJC: Is there documentation for a suspected LVO in the medical record?

    Element definition from Specifications Manual for Joint Commission National Quality Measures

    Collected for: STK-OP-1

    TJC Name: Suspected Large Vessel Occlusion (LVO)

    Definition: Documentation in the medical record for a suspected large vessel cerebral artery occlusion. Large vessel occlusions include documentation of a cerebral occlusion in the Internal Carotid Artery (ICA), ICA terminus (T-lesion; T occlusion), Middle Cerebral Artery (MCA), M1 MCA, Vertebral Artery, or Basilar Artery.

    Question: Is there documentation of a suspected LVO in the medical record?

    Format:

    Length - 1

    Type - Alphanumeric

    Occurs - 1

    Allowable Values:

    • Yes (There is documentation of a suspected LVO)
    • No (There is no documentation of a suspected LVO, OR unable to determine from the medical record)

    Notes for Abstraction:

    • If there is ANY documentation of LVO prior to transfer to another hospital, select "Yes". The percentage or degree of occlusion or stenosis is not needed to select ?#8364;œYes?#8364;? for this data element, e.g., "the patient has a LVO and requires transfer."
      • Documentation of LVO alone without the location of a specific cerebral artery is sufficient to select "Yes".
      • Disregard qualifiers describing the degree of occlusion, e.g., minimal/mild/moderate/high.
    • Documentation of suspected LVO, select "Yes".
    • Acceptable examples (select "Yes"):
      • Possible LVO requiring further evaluation.
      • High probability of left side ELVO.
      • Worrisome for ICA LVO.
      • Suspicious for left MCA territory ischemic CVA.
    • If an occlusion is documented in any of the following cerebral arteries, select "Yes": Internal Carotid Artery (ICA), ICA terminus (T-lesion; T occlusion), Middle Cerebral Artery (MCA), M1 MCA, M2 MCA, Vertebral Artery, or Basilar Artery.
      • A brain imaging report is not needed to select ?#8364;œYes?#8364;?, but may be used for abstraction. Findings / impression documented by a radiologist may be used for abstraction as well as other documentation available in the medical record.
      • The term LVO does not need to be linked with the cerebral artery.
    • If there is documentation in one source that indicates the patient has a LVO, AND there is documentation in another source that indicates the patient is NOT LVO (e.g., neurology report states positive for LVO, but radiology report states negative for LVO), the source that indicates the patient has LVO would be used for this data element. Contradictory or conflicting documentation select "Yes".
    • If after careful examination of circumstances, context, etc., documentation of LVO is still unclear, the case should be deemed "unable to determine" (select "No").

    Suggested Data Sources:

    • Consultation notes
    • Emergency department record
    • History and physical
    • Progress notes
    • Discharge summary
    • Diagnostic test reports

    Guidelines for Abstraction:

    Inclusion:

    • Evolving large vessel occlusion (ELVO)
    • Hyperdensity or hyperdense sign in a defined location.
    • Opacification
    • Sylvian occlusion

    Exclusion: None

    Admission Data, Hospitalization Data

    Summary of Changes


    REQUIRED FOR TJC: Is there documentation in the medical record that the patient is eligible for MER therapy or mechanical thrombectomy procedure?

    Element definition from Specifications Manual for Joint Commission National Quality Measures

    Collected for: STK-OP-1

    TJC Name: MER Eligibility

    Definition: Documentation in the medical record that the ischemic stroke patient is eligible for mechanical endovascular reperfusion (MER) therapy. MER therapy or mechanical thrombectomy is an advanced neurological procedure for removal of a cerebral occlusion using a mechanical device, also known as a clot retrieval device or stent retriever, and/or aspriation technique.

    Question: Is there documentation in the medical record that the patient is eligible for MER therapy or a mechanical thrombectomy procedure?

    Format:

    Length - 1

    Type - Alphanumeric

    Occurs - 1

    Allowable Values:

    • Yes (There is documentation that the patient is eligible for MER therapy or a mechanical thrombectomy procedure.)
    • No (There is no documentation that the patient is eligible for MER therapy or a mechanical thrombectomy procedure, OR unable to determine from the medical record documentation.)

    Notes for Abstraction:

    • Documentation by a physician/APN/PA that the patient is a candidate or eligible for MER therapy.
    • Documentation by a physician/APN/PA that the patient is being transferred to a higher level stroke center for the purpose of having a mechcanical thrombectomy procedure or further evaluation for possible MER therapy.

    Suggested Data Sources:

    • Consultation notes
    • Emergency department record
    • History and physical
    • Progress notes
    • Discharge summary
    • Diagnostic test reports

    Guidelines for Abstraction:

    Included:

    • Endovascluar Therapy (EVT)
    • Mechanical Endovascular Reperfusion (MER) Therapy
    • Mechanical Thrombectomy

    Exclusion:

  • None
  • Summary of Changes


    REQUIRED FOR COVERDELL ONLY: IA catheter-based treatment at this hospital?

    Indicate if IA catheter-based treatment for acute ischemic stroke was initiated at this hospital. IA catheter-based treatment therapy includes all uses of IA delivery of pharmacologic thrombolytic therapy, as well as mechanical devices such as "Clot retrieval devices" for acute ischemic stroke. Mechanical devices may be used alone or in conjunction with IA thrombolytic therapy. This field does not apply to endovascular treatments for other cerebrovascular conditions, such as stenting or angioplasty for subarachnoid hemorrhage induced vasospasm or elective carotid stenting for ischemic stroke prevention.

    • Yes
    • No

    Notes for Abstraction:

    • If catheter-based treatment for planned therapeutic intervention is initiated, but there is no visualized occlusion, then select “No”.
    • If IA thrombolytic therapy is given regionally (remote from clot due to an inability to access the clot), select “Yes.”
    • This data element is looking to capture patients that receive IA catheter-based reperfusion for acute stroke events only, and not those that undergo carotid revascularization for secondary prevention.
      • Select “No” for patients that undergo treatment for secondary prevention.
      • Select “No” for patients that undergo purely diagnostic angio or elective stenting.

    Inclusion Guidelines IA catheter-based treatment (see data element of: If IA catheter-based treatment at this hospital, type of treatment for additional clarity):

    • IA Thrombolytic
    • Retrievable stent
    • Other mechanical clot retriever device (not retrievable stent)
    • Clot suction device
    • Intracranial angioplasty, with or without permanent (non-retrieved stent)
    • Cervical carotid angioplasty, with or without stent
    • Other

     Exclusion Guidelines:

    • Catheter-based reperfusion for secondary prevention
    • Elective Stenting
    • Diagnostic angio

    Admission Data, Hospitalization Data

    Summary of Changes


    REQUIRED FOR COMPREHENSIVE AND COVERDELL: IA alteplase or MER Initiation Date/Time

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: IA alteplase or MER Initiation Date and Time

    Collected For: CSTK-05

    Definition: The date and the time (military time) that IA thrombolytic (alteplase) therapy or mechanical endovascular reperfusion (MER) therapy was initiated to a patient with ischemic stroke at this hospital. IA thrombolytics convert plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving thrombus. Reperfusion therapies also include procedures utilizing mechanical thrombectomy devices with or without pharmacological thrombolysis.

    Suggested Data Collection Question: What is the date and time that IA alteplase or MER was initiated at this hospital?

    Format

    Length:
    10 - MM-DD-YYYY (includes dashes) or UTD
                  5 - HH-MM (with or without colon) or UTD
    Type: Date/Time
    Occurs: 1

    Allowable Values:

    MM = Month (01-12)
    DD = Day (01-31)
    YYYY = Year (2001-Current Year)
    UTD = Unable to Determine

    HH = Hour (00-23)
    MM = Minutes (00-59)
    UTD = Unable to Determine

    Notes for Abstraction:

    • If the date IA alteplase or MER was initiated is unable to be determined from medical record documentation, select UTD.
    • The medical record must be abstracted as documented (taken at face value). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD.
      Example:
      Documentation indicates the MER initiation date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the MER initiation date is outside of the range listed in the Allowable Values for Day, it is not a valid date and the abstractor should select UTD.
      Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commission's Data Warehouse. Use of "UTD" for IA alteplase or MER Initiation Date allows the case to be accepted into the warehouse.
    • For times that include "seconds", remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00
    • The medical record must be abstracted as documented (taken at face value). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select UTD.
      Example:
      Documentation indicates the MER initiation time was 3300. No other documentation in the medical record provides a valid time. Since the MER initiation time is outside of the range listed in the Allowable Values for Hour, it is not a valid time and the abstractor should select "UTD".
      Note: Transmission of a case with an invalid time as described above will be rejected from the Joint Commission's Data Warehouse. Use of "UTD" for IA alteplase or MER Initiation Time allows the case to be accepted into the warehouse.
    • The earliest time should be used. If both IA alteplase and MER were initiated in the same procedure or different procedures, select the start time for the intervention that was done first.
      Example:
      "Patient entered the interventional suite at 1130. Anesthesia start time 1145. Groin puncture documented at 1151. IA infusion at 1205. Solataire deployed at 1229; second deployment 1243; Trevo deployed at 1310." Select 1205 for IA alteplase or MER Initiation Time.
    • If the time of therapy initiation is unable to be determined from medical record documentation, select "UTD".

    Suggested Data Sources:

    • Consultation notes
    • Progress notes
    • Operative notes
    • Diagnostic test reports
    • Procedure notes

    Guidelines for Abstraction

    Inclusion: None

    Exclusion: None

    OPTIONALCatheter-based stroke treatment at outside hospital?


    Definition: Indicate if IA catheter-based treatment was initiated at an outside hospital prior to transfer to your hospital?

    Data Collection Question: Was IA catheter-based treatment for acute ischemic stroke was initiated at an outside hospital?

    Format: Single-select

    Allowable Values:
    • Yes
    • No


    Notes for Abstraction:
    • This field does not apply to endovascular treatments for other cerebrovascular conditions, such as stenting or angioplasty for subarachnoid hemorrhage induced vasospasm or elective carotid stenting for ischemic stroke prevention.
    • Select Yes If IA therapy is given regionally (remote from clot due to an inability to access the clot).
    • Select No if catheter-based treatment for planned therapeutic intervention is initated, but there is no visualized occulusion.
    • Select No for patients that undergo treatment for secondary prevention.
    • Select No for patients that undergo purely diagnostic angio or elective stenting.
    • Inclusion Guidelines IA catheter-based treatment type:
    • IA Thrombolytic
    • Retrievable stent
    • Other mechanical clot retriever device (not retrievable stent)
    • Clot suction device
    • Intracranial angioplasty, with or without permanent (non-retrieved stent)
    • Cervical carotid angioplasty, with or without stent
    • Other
    • Exclusion Guidelines:
    • Catheter-based reperfusion for secondary prevention
    • Elective Stenting
    • Diagnostic angio


    • Suggested Data Sources:
    • Admission Data
    • Hospitalization Data

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: What is the date and time that IA thrombolytic therapy was initiated for this patient at this hospital?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: IA Thrombolytic Initiation Date/Time

    Collected For: CSTK-07

    Definition: The date and the time (military time) that Intra-arterial (IA) thrombolytic therapy was initiated to a patient with ischemic stroke at this hospital. IA thrombolytics convert plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving thrombus.

    Suggested Data Collection Question: What is the date and time that IA thrombolytic therapy was initiated for this patient at this hospital?

    Format

    Length:
    10 - MM-DD-YYYY (includes dashes) or UTD, 5 - HH-MM (with or without colon) or UTD
    Type: Date/Time
    Occurs: 1

    Allowable Values:

    MM = Month (01-12)
    DD = Day (01-31)
    YYYY = Year (2001-Current Year)
    UTD = Unable to Determine

    HH = Hour (00-23)
    MM = Minutes (00-59)
    UTD = Unable to Determine

    Notes for Abstraction:

    • If the date IA thrombolytic therapy was initiated is unable to be determined from medical record documentation, select "UTD".
    • The medical record must be abstracted as documented (taken at "face value"). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select "UTD".
      Example:
      Documentation indicates the IA thrombolytic initiation date was 03-*42*-20xx. No other documentation in the medical record provides a valid date. Since the IA thrombolytic initiation date is outside of the range listed in the Allowable Values for "Day," it is not a valid date and the abstractor should select "UTD".
      Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commission's Data Warehouse. Use of "UTD" for IA Thrombolytic Initiation Date allows the case to be accepted into the warehouse.
    • Use the time at which initiation of the IA thrombolytic was first documented. If a discrepancy exists in time documentation from different sources, choose the earliest time. If there are two or more different IA thrombolytic initiation times (either different IA thrombolytic episodes or corresponding with the same episode), enter the earliest time.
    • For times that include "seconds", remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00
    • IA thrombolytic initiation time refers to the start time of the thrombolytic bolus/infusion.
    • If the time of IA thrombolytic initiation is unable to be determined from medical record documentation, select "UTD".
    • The medical record must be abstracted as documented (taken at "face value"). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select "UTD".
      Example:
      Documentation indicates the IA thrombolytic initiation time was 3300. No other documentation in the medical record provides a valid time. Since the IA thrombolytic initiation time is outside of the range listed in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "UTD".
      Note: Transmission of a case with an invalid time as described above will be rejected from the Joint Commission's Data Warehouse. Use of "UTD" for IA Thrombolytic Initiation Time allows the case to be accepted into the warehouse.

    Suggested Data Sources:

    • Consultation notes
    • Operative notes
    • Diagnostic test reports
    • Procedure notes

    Guidelines for Abstraction

    Inclusion: None

    Exclusion: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: Is there documentation in the medical record of the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: First Pass of a Mechanical Reperfusion Device

    Collected For: CSTK-07

    Definition: First pass (i.e., deployment) of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital. A mechanical reperfusion device is also known as a clot retrieval device. Clot retrieval devices are designed to treat ischemic stroke by removal of the clot from the cerebral artery. Several brand names are used to identify clot retrieval devices which include, Merci, Penumbra, Trevo, and Solataire. For purposes of this data element, "pass" means mechanical deployment of a clot retrieval device.

    Suggested Data Collection Question: Is there documentation in the medical record of the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital?

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    Y (Yes) There is documentation of the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital.

    N (No) There is no documentation of the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital, OR unable to determine from medical record documentation.

    Notes for Abstraction:

    • If the first pass of the mechanical reperfusion device at this hospital is unable to be determined from medical record documentation, select No.
    • If a diagnostic test report conflicts with other sources documenting the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery, use the documentation found in the diagnostic test report.

    Suggested Data Sources:

    • Consultation notes
    • Diagnostic test reports
    • Operative notes
    • Procedure notes

    Guidelines for Abstraction

    Inclusion:

    • Deployment
    • Pass
    • Access
    • Advance
    • Aspiration
    • Attempt
    • Run

    Exclusion: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE:

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: First Pass Date/Time

    Collected For: CSTK-07

    Definition: The date and the time of the first pass (i.e., mechanical deployment) of a clot retrieval device at this hospital.

    Suggested Data Collection Question: What is the date and time of the first pass of a clot retrieval device at this hospital?

    Format

    Length:
    10 - MM-DD-YYYY (includes dashes) or UTD, 5 - HH-MM (with or without colon) or UTD
    Type: Date/Time
    Occurs: 1

    Allowable Values:

    MM = Month (01-12)
    DD = Day (01-31)
    YYYY = Year (2001-Current Year)
    UTD = Unable to Determine

    HH = Hour (00-23)
    MM = Minutes (00-59)
    UTD = Unable to Determine

    Notes for Abstraction:

    • If the date of the first pass is unable to be determined from medical record documentation, select UTD.
    • The medical record must be abstracted as documented (taken at face value). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD
      Examples:
      • Documentation indicates the first pass date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the first pass date is outside of the range listed in the Allowable Values for Day, it is not a valid date and the abstractor should select UTD.
        • Patient expires on 02-12-20xx and documentation indicates the First Pass Date was 03-12-20xx. Other documentation in the medical record supports the date of death as being accurate. Since the First Pass Date is after the Discharge Date (death), it is outside of the parameters of care and the abstractor should select "UTD."
      Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commissions Data Warehouse. Use of UTD for First Pass Date allows the case to be accepted into the warehouse.
    • For times that include "seconds", remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00.
    • If the First Pass Time is unable to be determined from medical record documentation, select UTD.
    • The medical record must be abstracted as documented (taken at face value). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select UTD.
      Example:
      Documentation indicates the first pass time was 3300. No other documentation in the medical record provides a valid time. Since the first pass time is outside of the range listed in the Allowable Values for Hour, it is not a valid time and the abstractor should select UTD.
      Note: Transmission of a case with an invalid time as described above will be rejected from the Joint Commissions Data Warehouse. Use of UTD for First Pass Time allows the case to be accepted into the warehouse.
    • The earliest time should be used regardless of how many vessels were treated or which ones were successful vs. unsuccessful.

    Suggested Data Sources:

    • Consultation notes
    • Operative notes
    • Diagnostic test reports
    • Procedure notes

    Guidelines for Abstraction

    Inclusion: None

    Exclusion:

    • Anesthesia start time
    • Groin puncture time
    • Procedure start time

    Summary of Changes

     

    OPTIONAL COMPREHENSIVE: If MER treatment at this hospital, type of treatment

    • Retrievable stent
    • Other mechanical clot retriever device (not retrievable stent)
    • Clot suction device
    • Intracranial angioplasty, with or without permanent (non-retrieved stent)
    • Cervical carotid angioplasty, with or without stent
    • Other

    Notes for Abstraction:

    • Examples of a Retrievable stent would include (but are not limited to): Solitaire and Trevo
    • Examples of an Other Mechanical Clot Retriever would include (but are not limited to): Merci Retrieval System
    • Example of a Clot Suction Device would include (but is not limited to): Penumbra Stroke System

    Admission Data, Hospitalization Data

    REQUIRED FOR COMPREHENSIVE: What is the location of the clot in the cerebral circulation?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Proximal or Distal Occlusion

    Collected For: CSTK-08

    Definition: Documentation in the medical record of the location of the clot in either the large arteries in the neck or base of the brain (proximal), or small arteries higher up in the brain (distal). Arterial occlusions arising more proximally are associated with poorer outcomes.

    Suggested Data Collection Question: What is the location of the clot in the cerebral circulation?

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    1 Proximal cerebral occlusion

    2 Distal cerebral occlusion

    3 Neither proximal or distal, OR unable to determine (UTD) from the medical record documentation

    Notes for Abstraction:

    • If the occlusion is documented in an artery listed as an inclusion term for "proximal", select ‘1’.
    • If the occlusion is documented in an artery listed as an inclusion term for "distal", select ‘2’.
    • If multiple occlusions, select "proximal" or "distal" for the primary vessel occlusion.
    • If unable to determine, select ‘3’.

    Suggested Data Sources:

    • Consultation notes
    • Emergency department record
    • History and physical
    • Progress notes
    • Discharge summary
    • Diagnostic test reports
    • Operative notes
    • Procedure notes
    • Admitting notes
    • Procedure reports

    Guidelines for Abstraction:

     

    Inclusion

    Exclusion

    PROXIMAL:
    • Internal Carotid Artery (ICA)
    • ICA terminus
    • Middle Cerebral Artery (MCA)
    • Middle Cerebral Artery (MCA) M1 segment
    • M1
    • T-occlusion (T-lesion) 
    • Vertebral Artery
    • Basilar Artery

    DISTAL:
    • Anterior Cerebral Artery (ACA)
    • Anterior Cerebral Artery (ACA) A1 segment
    • A1
    • Anterior Cerebral Artery (ACA) A2 segment
    • A2
    • Anterior Cerebral Artery (ACA) A3 segment 
    • A3 
    • Middle Cerebral Artery (MCA) M2 segment  
    • M2
    • Middle Cerebral Artery (MCA) M3 segment
    • M3
    • Middle Cerebral Artery (MCA) M4 segment
    • M4
    • Posterior Cerebral Artery (PCA) 
    • Posterior Cerebral Artery (PCA) P1 segment 
    • P1 
    • Posterior Cerebral Artery (PCA) P2 segment 
    • P2 
    • Posterior Cerebral Artery (PCA) P3 segment
    • P3

    None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: What cerebral artery is occluded?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Site of Primary Vessel Occlusion

    Collected For: CSTK-08

    Definition: Documentation in the medical record of the clinical location of the primary occluded vessel.

    Suggested Data Collection Question: What cerebral artery is occluded?

    Format

    Length:
    2
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    1 Anterior cerebral artery (ACA)

    2 A1 ACA

    3 Anterior communicating artery

    4 Internal carotid artery (ICA)

    5 ICA terminus (T-lesion; T-occlusion)

    6 Middle cerebral artery (MCA)

    7 M1 MCA

    8 M2 MCA

    9 M3/M4 MCA

    10 Vertebral artery (VA)

    11 Basilar artery (BA)

    12 Posterior cerebral artery (PCA)

    13 Other cerebral artery branch/segment

    14 The clinical location of the primary occluded vessel was not documented, OR unable to determine (UTD) from the medical record documentation.

    Notes for Abstraction:

    • Collect the documented clinical location of the primary occluded arterial segment treated with IA thrombolytic (alteplase) therapy and/or mechanical endovascular reperfusion therapy.

    Suggested Data Sources:

    • Consultation notes
    • Emergency department record
    • History and physical
    • Progress notes
    • Discharge summary
    • Diagnostic test reports
    • Operative notes
    • Procedure notes
    • Admitting notes
    • Procedure reports

    Guidelines for Abstraction

    Inclusion: None

    Exclusion: None

    Summary of Changes

    OPTIONAL: Investigational or experimental protocol for thrombolysis

    Indicate whether or not medical records suggest that some kind of investigational thrombolytic protocol was used during provision of care. If investigational or experimental protocol was used there should be a signed IRB consent in the medical record.

    • Yes
    • No

    Admission Data, Hospitalization Data

    OPTIONAL: If yes, Specify

    If some kind of investigational or experimental protocol for thrombolysis was used, please describe the nature of the experimental protocol in this text box.

    ^^Thrombolysis in Cerebral Infarction (TICI) Post-Treatment Reperfusion Grade

    Collected For: GWTG EVT Measure Set

    Definition: The Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade is used to measure cerebral reperfusion. Results with this scoring system range between zero and three: 0 (no perfusion); 1 (perfusion past the initial occlusion, but no distal branch filling); 2 (perfusion with incomplete or slow distal branch filling); and, 3 (full perfusion with filling of all distal branches). Reperfusion past the target arterial occlusion and into the distal arterial bed and terminal branches, in conjunction with recanalization of the target arterial occlusion, demonstrates flow restoration or revascularization.

    Question: Thrombolysis in Cerebral Infarction (TICI) Post-Treatment Reperfusion Grade

    Format: Single Select

    Allowable Values:

    • Grade 0
    • Grade 1
    • Grade 2a:
    • Grade 2b
    • Grade 3
    • ND

    Notes for Abstraction:

    • Grade 0: No Perfusion. No antegrade flow beyond the point of occlusion.
    • Grade 1: Penetration With Minimal Perfusion. The contrast material passes beyond the area of obstruction but fails to opacify the entire cerebral bed distal to the obstruction for the duration of the angiographic run.
    • Grade 2a: Partial tissue reperfusion in < 50% of the occluded artery.
    • Grade 2b: Partial reperfusion in ≥ 50% of the occluded artery territory.
    • Grade 3: Essentially complete Perfusion. Antegrade flow into the bed distal to the obstruction occurs as promptly as into the obstruction and clearance of contrast material from the involved bed is as rapid as from an uninvolved other bed of the same vessel or the opposite cerebral artery.
    • Select "Grade 2b" if documentation includes 2b, 2c, or a grade 2 with any modifier that indicates 50 -99 percent reperfusion.
    • If a TICI reperfusion grade was not done post treatment or cannot be determined from medical record documentation, select “ND.”
    • TICI grade must be documented by a Physician/APN/PA.
    • Rationale: Endovascular therapy (EVT) is now the standard of care for treatment of acute ischemic stroke due to large-vessel occlusion (LVO). In 2015, the American Heart Association/American Stroke Association published a focused update to the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke regarding endovascular treatment (Powers WJ, et. al., 2015). Endovascular therapy with a stent retriever is recommended for eligible patients. To ensure benefit, reperfusion to TICI 2B/3 should be achieved as early as possible and within 6 hours of stroke onset. As with IV alteplase, reduced time from symptom onset to reperfusion with EVT is highly associated with better clinical outcomes.

    Suggested Data Sources:

    • Consultation Notes
    • Diagnostic Test Reports
    • Procedure Reports

    Additional Notes / Guidelines for Abstraction:

    • Sang Hyun Suh, Harry J. Cloft, Jennifer E. Fugate, Alejandro A. Rabinstein, David S. Liebeskind and David F. Kallmes    Stroke. 2013;44:1166-1168.

    REQUIRED FOR COMPREHENSIVE: Is there a documented TICI reperfusion gradepost-treatment?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade

    Collected For: CSTK-08

    Definition: Documentation that the Thrombolysis in Cerebral Infarction (TICI) reperfusion grade was 2B (i.e., partial perfusion greater than or equal to 50% of vascular distribution of occulded artery) or higher post-treatment. The TICI scale is a tool used to grade the degree of perfusion obtained following recanalization of an arterial occlusion. Recanalization of an arterial occlusion increases reperfusion into distal segments of the artery and restores blood flow to brain tissue. Scores may range from 0 (no perfusion) to 3 (full perfusion with filling of all distal branches).

    Suggested Data Collection Question: Is there a documented TICI reperfusion gradepost-treatment?

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    1 A TICI reperfusion grade greater than or equal to (≥) 2B was documented post-treatment.

    2 A TICI reperfusion grade less than (<) 2B was documented post-treatment.

    3 A TICI reperfusion grade was not done post-treatment, OR Unable to determine (UTD) from the medical record documentation.

    Notes for Abstraction:

    • The TICI grade may be documented by the physician/APN/PA, or a nurse (RN), circulating nurse, or operating room technician designated to scribe during the procedure.
    • When multiple TICIs are documented because more than one vessel or branches of an artery are occluded, select the TICI grade associated with the site of primary vessel occlusion.
    • If unable to determine whether the TICI reflects reperfusion of the primary vessel, then select "UTD".

    Suggested Data Sources:

    • Consultation notes
    • Emergency department record
    • History and physical
    • Progress notes
    • Discharge summary
    • Diagnostic test reports
    • Operative notes
    • Procedure notes
    • Admitting notes

    Guidelines for Abstraction

    Inclusion: None

    Exclusion:

    • TIBI
    • TIMI
    • Scoring methodologies other than TICI

    Summary of Changes

    OPTIONAL COMPREHENSIVE: Surgical treatment for ICH at this hospital?

    Indicate if surgical treatment was initiated at this hospital for ICH.

    • Yes
    • No

    Admission Data, Hospitalization Data

    OPTIONAL COMPREHENSIVE: If Surgical treatment for ICH at this hospital, type

    • External Ventricular Drain (EVD)
    • Endoscopic evacuation
    • Conventional craniotomy and evacuation of clot under direct vision
    • Stereotactic evacuation
    • Hemicraniotomy without clot evacuation
    • Fibrinolytic infusion via catheter
    • Other

    Admission Data, Hospitalization Data

    OPTIONAL COMPREHENSIVE: If ICH was evacuated, time from ictus to evacuation procedure start was:

    Enter the time, in hours, between ictus and surgery. The start of surgery is defined as the time documented in the operative or procedure note.

    Admission Data, Hospitalization Data

    Additional Comments Related to Thrombolytics

    Use this text box to enter any additional comments related to thrombolytic therapy


    Complications of Thrombolytic Therapy

    REQUIRED: Complications of Reperfusion therapy (Thrombolytic or MER) (Check all that apply)

    Indicate if there were any complications from the thrombolytic or MER therapy.

    • Symptomatic intracranial hemorrhage <36 hours
    • Life threatening, serious systemic hemorrhage <36 hours
    • Other serious complications
    • No serious complications
    • UTD

    Notes for Abstraction:

    • Symptomatic brain hemorrhage is defined by a CT within 36 hours that shows intracranial hemorrhage AND physician's notes indicate clinical deterioration due to hemorrhage.
    • Life threatening, serious systemic hemorrhage is defined by bleeding within 36 hours of thrombolytic therapy or MER and > 3 transfused units of blood within 7 days or discharge (whichever is earlier) AND physician note attributing bleeding problem as reason for transfusion
    • Other serious complications are those that require additional medical interventions or prolonged length of stay. Serious complications include those that are unexpected or out of proportion to the patient's expected course and that are documented as complications of reperfusion therapy. For example, rapid development of malignant edema, angioedema, or recurrent stroke. If complications do not require additional medical interventions or prolong the length of stay, select "No serious complications".
    • Select "UTD" if worsening stroke symptoms or in-hospital death without definitive evidence of a complication listed above (such as hemorrhage).

    Example: Patient 190a received intravenous thrombolytics in the ED on 07/01/20XX. The following day the patient developed a sudden headache and decreased level of consciousness. A head CT was performed which showed a large intracerebral hemorrhage. Select "Symptomatic intracranial hemorrhage < 36 hours."

    Admission Data, Hospitalization Data, Radiology notes, Discharge Data

    Summary of Changes

    REQUIRED: If bleeding complications occur in patient transferred after IV alteplase

    Indicate if hemorrhagic complications of alteplase within 36 hours from the time of alteplase bolus, as defined above, occurred in a patient transferred to another healthcare facility after IV alteplase (Intravenous alteplase) administration.

    • Symptomatic hemorrhage detected prior to patient transfer
    • Symptomatic hemorrhage detected only after patient transfer
    • Unable to determine
    • N/A

    Notes for Abstraction:

    • If symptomatic brain or systemic hemorrhage was detected or strongly suspected prior to transfer, select "symptomatic hemorrhage detected prior to patient transfer". Select this option if the patient has hemodynamic instability suggesting systemic hemorrhage, or a deterioration in the neurologic exam suggesting intracerebral hemorrhage while still at the initial treating hospital, even if the testing which confirms the finding doesn't occur until after transfer.
    • If symptomatic brain or systemic hemorrhage is not detected or strongly suspected prior to transfer, and occurs only after the patient has left the initial treating facility, select "symptomatic hemorrhage detected only after patient transfer".
    • If it is not possible to obtain information from the hospital at which the patient received IV alteplase prior to transfer (if you are the receiving hospital), or to which you transferred the patient after starting IV alteplase (if you are the initial treating hospital), select "unable to determine". Note that the Federal Privacy Rule (HIPAA) does not restrict the communication of protected health information when performed for quality assurance purposes. To avoid interfering with an individual's access to quality health care or the efficient payment for such health care, the Privacy Rule permits a covered entity to use and disclose protected health information, with certain limits and protections, for treatment, payment, and health care operations activities. [These health care operations activities include] conducting quality assessment and improvement activities, population based activities relating to improving health or reducing health care costs, and case management and care coordination; Reviewing the competence or qualifications of health care professionals, evaluating provider and health plan performance, training health care and non-health care professionals, accreditation, certification, licensing, or credentialing activities [from The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, enacted on August 21, 1996.]
    • Also select "Unable to determine" in case of patient death without confirmed hemorrhage.
    • If no tPA given, or if the patient is not transferred after IV-tPA (patient remains at your hospital), then this element is not applicable. Select N/A.

    Examples:

    • Patient 200a received intravenous tPA in the ED at TMC on 07/01/04 at 11:00 and was transferred to GMC at 13:00. The following day at GMC the patient developed a sudden headache and decreased level of consciousness. A head CT was performed which showed a large intracerebral hemorrhage. Select "symptomatic hemorrhage detected only after patient transfer". If the symptoms began in the ambulance after leaving TMC, you would still select "symptomatic hemorrhage detected only after patient transfer".
    • Patient 200b received intravenous tPA in the ED at TMC on 07/01/04 at 11:00 and developed a sudden headache and decreased level of consciousness prior to transfer to GMC at 13:00. Upon arrival at GMC, a head CT was performed which showed a large intracerebral hemorrhage. Select "symptomatic hemorrhage detected prior to patient transfer".
    • Patient 200c received intravenous tPA in the ED at TMC on 07/01/04 at 11:00 and was transferred to GMC at 13:00. Despite a request by the staff at TMC to the Stroke Center director at GMC, no further information can be obtained about the patient after transfer. Select "unable to determine"

    Admission Data, Hospitalization Data, Radiology notes, Discharge Data 

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: What is the last NIHSS score documented prior to initiation of IV thrombolytic therapy at this hospital?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: NIHSS Score Documented Closest to IV Thrombolytic Initiation

    Collected For: CSTK-05

    Definition: The NIHSS score documented closest to IV thrombolytic initiation is the last NIHSS score documented prior to IV thrombolytic initiation at this hospital. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language.

    Suggested Data Collection Question: What is the last NIHSS score documented prior to initiation of IV thrombolytic therapy at this hospital?

    Format

    Length:
    3
    Type: Alphanumeric
    Occurs:1

    Allowable Values:
    Score = 0-42
    UTD = Unable to Determine

    Notes for Abstraction:

    • The NIHSS score may be documented by the physician/APN/PA or nurse (RN).
    • Look for the last NIHSS score documented prior to IV thrombolytic initiation at this hospital.
      Examples:
      • "Initial NIHSS score 4 documented by the ED nurse at this hospital. "No other NIHSS scores were documented prior to IV alteplase initiation." Select '4'.
      • "Symptoms resolved by time of hospital arrival at 1200. Initial NIHSS score zero documented in ED. Symptoms returned at 1330, NIHSS score 2, and IV alteplase given at 1338." Select '2'.
      • "Patient transferred to this hospital. NIHSS score 10 done at transferring hospital. No NIHSS score documented at this hospital prior to IV alteplase." Select '10'.
      • "Nurse documented NIHSS score 8 via telemedicine prior to arrival at this hospital. IV alteplase initiated at 1712. NIHSS score 2 at 1800." Select '8'.
    • For purposes of this data element, score documentation between 0 and 42 is acceptable. Only one score may be selected. Select the last NIHSS score documented prior to IV Thrombolytic Initiation Time at this hospital
    • If only one NIHSS score is documented prior to IV thrombolytic initiation and no other score(s) are available for comparison, enter the value for that score.
    • If no NIHSS score is documented prior to IV thrombolytic initiation, select UTD.
    • If unable to determine the last NIHSS score documented prior to IV thrombolytic initiation, select UTD.

    Suggested Data Sources:

    • Consultation notes
    • History and physical
    • Nursing flow sheet
    • Progress notes
    • Transfer sheet
    • Admitting note
    • Ambulance record
    • Emergency room records
    • Nursing assessment

    Guidelines for Abstraction

    Inclusion: None

    Exclusion:

    • Modified NIHSS scores
    • Estimated NIHSS scores
    • Scoring methodologies other than NIHSS

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: What is the last NIHSS score documented prior to initiation of IA alteplase or MER at this hospital?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: NIHSS Score Documented Closest to IA alteplase or MER Initiation

    Collected For: CSTK-05

    Definition: The NIHSS score documented closest to IA thrombolytic (alteplase) therapy or mechanical endovascular reperfusion (MER) therapy initiation is the last NIHSS score documented prior to IA alteplase or MER initiation (i.e., the initiation time of the intervention performed first) at this hospital. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language.

    Suggested Data Collection Question: What is the last NIHSS score documented prior to initiation of IA alteplase or MER at this hospital?

    Format

    Length:
    3
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:
    Score = 0-42
    UTD = Unable to Determine

    Notes for Abstraction:

    • The NIHSS score may be documented by the physician/APN/PA or nurse (RN).
    • Look for the last NIHSS score documented prior to IA alteplase or MER initiation at this hospital.
      Examples:
      • "Initial NIHSS score 4 documented by the ED nurse at this hospital. No other NIHSS scores were documented prior to IA alteplase or MER initiation." Select '4'.
      • "NIHSS score 6 prior to transfer to this hospital. IV alteplase 'drip and ship'. Arrival Time at this hospital 2319. NIHSS score 8 at 2325 and NIHSS score 10 at 2340. IA Thrombolytic Initiation Time 0015." Select '10'.
      • "NIHSS score 10 on arrival. IV alteplase given at 0800. NIHSS score 8 at 0900. IA infusion start time 0950." Select '8'.
      • "IV alteplase given at a transferring hospital. Nurse documented NIHSS score 18 via telemedicine prior to arrival at this hospital. Patient went directly to OR for mechanical thrombectomy procedure. No NIHSS score documented at this hospital prior to intervention." Select '18'.
    • For purposes of this data element, score documentation between 0 and 42 is acceptable. Only one score may be selected. Select the last NIHSS score documented prior to the start time of IA alteplase OR first pass of a mechanical reperfusion device whichever intervention is performed first, i.e. "IA alteplase first then MER" or "MER first then IA alteplase", at this hospital.
    • If only one NIHSS score is documented prior to IA alteplase or MER initiation and no other score(s) are available for comparison, enter the value for that score.
    • If no NIHSS score is documented prior to IA alteplase or MER initiation, select UTD.
    • If unable to determine the last NIHSS score documented prior to IA alteplase or MER initiation, select UTD.

    Suggested Data Sources:

    • Consultation notes
    • History and physical
    • Nursing flow sheet
    • Progress notes
    • Transfer sheet
    • Admitting note
    • Ambulance record
    • Emergency room records
    • Nursing assessment

    Guidelines for Abstraction

    Inclusion: None

    Exclusion:

    • Modified NIHSS scores
    • Estimated NIHSS scores
    • Scoring methodologies other than NIHSS

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: What is the highest NIHSS score documented within 36 hours following initiation of IV (alteplase) thrombolytic therapy?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Highest NIHSS Score Documented Within 36 Hours Following IV Thrombolytic Initiation

    Collected For: CSTK-05

    Definition: The highest NIHSS score documented within 36 hours following initiation of IV thrombolytic (alteplase) therapy. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language.

    Suggested Data Collection Question: What is the highest NIHSS score documented within 36 hours following initiation of IV (alteplase) thrombolytic therapy?

    Format

    Length:
    3
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:
    Score = 0-42
    UTD = Unable to Determine

    Notes for Abstraction:

    • The NIHSS score may be documented by the physician/APN/PA or nurse (RN).
    • Look for the highest NIHSS score documented in less than or equal to 36 hours following initiation of IV thrombolytic (alteplase) therapy.
    • For purposes of this data element, score documentation between 0 and 42 is acceptable.
    • If only one NIHSS score is documented within the first 36 hours following initiation of IV thrombolytic (alteplase) therapy and no other NIHSS score(s) are available for comparison, enter the value for that score.
    • If multiple scores are documented within the first 36 hours following initiation of IV thrombolytic (alteplase) therapy, select the highest score.
      EXAMPLES:
      • NIHSS Score is 10 at 1500 and 20 at 2300. Both scores are documented following the initiation of IV thrombolytic therapy. Select NIHSS score of 20.
      • IV thrombolytic therapy initiated on 9/5/20XX at 0900. NIHSS score is 8 on 9/5/20XX at 2300, 10 on 9/6/20XX at 0100, and 8 on 9/6/20XX at 0300. Select NIHSS score 10.
      • IV thrombolytic therapy initiated on 9/5/20XX at 0900. NIHSS score 3 on 9/6/20XX at 0900, 2 on 9/8/20XX at 0900, and 6 on 9/10/2012 at 0900. Select 3.
    • If no NIHSS score is documented within 36 hours following IV thrombolytic (alteplase) therapy, select UTD.
    • If unable to determine the highest score documented within 36 hours following IV thrombolytic (alteplase) therapy, select UTD.

    Suggested Data Sources:

    • Consultation notes
    • History and physical
    • Nursing flow sheet
    • Progress notes
    • Admitting note
    • Nursing assessment

    Guidelines for Abstraction

    Inclusion: None

    Exclusion:

    • Modified NIHSS scores
    • Estimated NIHSS scores
    • Scoring methodologies other than NIHSS

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: What is the highest NIHSS score documented within 36 hours following IA alteplase or MER initiation?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Highest NIHSS Score Documented Within 36 Hours Following IA alteplase or MER Initiation

    Collected For: CSTK-05

    Definition: The highest NIHSS score documented within 36 hours following initiation of IA thrombolytic (alteplase) therapy or mechanical endovascular reperfusion therapy (MER). The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language.

    Suggested Data Collection Question: What is the highest NIHSS score documented within 36 hours following IA alteplase or MER initiation?

    Format

    Length:
    3
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:
    Score = 0-42
    UTD = Unable to Determine

    Notes for Abstraction:

    • The NIHSS score may be documented by the physician/APN/PA or nurse (RN).
    • Look for the highest NIHSS score documented in less than or equal to 36 hours following initiation of IA alteplase or MER therapy.
    • For purposes of this data element, score documentation between 0 and 42 is acceptable.
    • If only one NIHSS score is documented within the first 36 hours following initiation of IA alteplase or MER therapy and no other NIHSS score(s) are available for comparison, enter the value for that score.
    • If multiple scores are documented within the first 36 hours following initiation of IA alteplase or MER therapy, select the highest score.
      EXAMPLES:
      • IA alteplase initiated at 1247 with first deployment of a mechanical reperfusion device at 1303. NIHSS Score is 10 at 1500 and 20 at 2300. Select NIHSS score of 20.
      • IA alteplase infusion initiated on 9/5/20XX at 0900. NIHSS score is 8 on 9/5/20XX at 2300, 10 on 9/6/20XX at 0100, and 8 on 9/6/20XX at 0300. Select NIHSS score 10.
      • MER initiated on 9/5/20XX at 0900. NIHSS score 3 on 9/6/20XX at 0900, 2 on 9/8/20XX at 0900, and 6 on 9/10/2012 at 0900. Select 3.
    • If no NIHSS score is documented within 36 hours following IA alteplase or MER therapy initiation, select UTD.
    • If unable to determine the highest score documented within 36 hours following IA alteplase or MER therapy initiation, select UTD.

    Suggested Data Sources:

    • Consultation notes
    • Emergency department record
    • History and physical
    • Nursing flow sheet
    • Progress notes
    • Admitting note
    • Nursing assessment

    Guidelines for Abstraction

    Inclusion: None

    Exclusion:

    • Modified NIHSS scores
    • Estimated NIHSS scores
    • Scoring methodologies other than NIHSS

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: Was there a positive finding on brain imaging of parenchymal hematoma, SAH, and/or IVH following IV or IA thrombolytic (alteplase) therapy, or mechanical endovascular reperfusion therapy initiation?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Positive Brain Image

    Collected For: CSTK-05

    Definition: Documentation of a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage following IV or IA thrombolytic (alteplase) therapy, OR mechanical endovascular reperfusion therapy initiation. The major risk of reperfusion therapy is hemorrhage

    Suggested Data Collection Question: Was there a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage following IV or IA thrombolytic (alteplase) therapy, or mechanical endovascular reperfusion therapy initiation?

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    Y (YES) Parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was detected on brain imaging following IV or IA thrombolytic (alteplase) therapy, or mechanical endovascular reperfusion therapy initiation.

    N (No) Parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was not detected on brain imaging following IV or IA thrombolytic (alteplase) therapy, or mechanical endovascular reperfusion therapy initiation, OR Unable to determine (UTD) from the medical record documentation.

    Notes for Abstraction:

    • For purposes of this data element, do not use brain imaging reports for CT/MRI performed prior to IV or IA thombolytic (alteplase) initiation, or mechanical endovascular reperfusion (MER) therapy. Abstract only brain imaging reports for tests done after these interventions to select 'YES'.
    • Patients with a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage on brain imaging following IV or IA thrombolytic (alteplase) therapy, or mechanical endovascular reperfusion therapy initiation, are acceptable to select Yes.
      • A confirmed report is not necessary. Reports of preliminary findings within this timeframe may be used in abstraction.
      • If the report documents that hemorrhage cannot be excluded, cannot R/O hemorrhage, or findings suggestive of hemorrhage, select Yes.
    • When conflicting information is documented in the medical record, select 'YES'.
    • Documentation that the hemorrhage is "old", select 'NO'. Do not infer that a hemorrhage is old unless explicitly documented.
    • See the inclusion list for acceptable examples of documentation of a positive finding. The list is not all inclusive.

    Suggested Data Sources:

    ONLY acceptable data source

    • Brain imaging reports
    • Diagnostic test reports
    • Radiology reports

    Guidelines for Abstraction

    Inclusion:

    • Bleed
    • Brain hemorrhage
    • Cerebral hemorrhage
    • ECASS criteria PH1 or PH2
    • Hemorrhage
    • Hemorrhagic conversion
    • Hemorrhagic expansion
    • Hemorrhagic transformation
    • Intracerebral hemorrhage (ICH)
    • Intraventricular hemorrhage
    • Parenchymal hematoma
    • Parenchymal hemorrhage
    • Parenchymal intracerebral hemorrhage
    • Subarachnoid hemorrhage (SAH)

    Exclusion: None

    • ECASS criteria H1 or H2
    • Incidental
    • Micro
    • Petechial
    • Trace

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: Date/Time of positive brain image

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Positive Brain Image Date/Time

    Collected For: CSTK-05

    Definition: The month, date, year and time for which a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was documented. Early hemorrhagic transformation occurs in about one in ten patients with acute ischemic stroke, but only parenchymal hematoma predicts poor outcomes, according to the research.

    Suggested Data Collection Question: What was the date and time of the positive brain image finding?

    Format

    Length:
    10 - MM-DD-YYYY (includes dashes) or UTD, 5 - HH-MM (with or without colon) or UTD
    Type: Date/Time
    Occurs: 1

    Allowable Values:

    MM = Month (01-12)
    DD = Day (01-31)
    YYYY = Year (2001-Current Year)
    UTD = Unable to Determine


    HH = Hour (00-23)
    MM = Minutes (00-59)
    UTD = Unable to Determine

    Notes for Abstraction:

    • Use the date when a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was first documented following IV or IA thrombolytic (t-PA) therapy, or mechanical endovascular reperfusion therapy initiation. If a discrepancy exists in date documentation from different sources, choose the earliest date. If there are two or more different positive brain image dates (either different brain images or corresponding with the same brain image), enter the earliest date.
    • If the date of positive brain image is unable to be determined from medical record documentation, select UTD.
    • The medical record must be abstracted as documented (taken at face value). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD.
      Example:
      Documentation indicates the positive brain image date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the positive brain image date is outside of the range listed in the Allowable Values for Day, it is not a valid date and the abstractor should select UTD.
      Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commissions Data Warehouse. Use of UTD for Positive Brain Image Date allows the case to be accepted into the warehouse.
    • Use the time at which symptomatic intracranial hemorrhage was first documented following IV or IA thrombolytic (alteplase) therapy, or mechanical endovascular reperfusion therapy initiation. If a discrepancy exists in time documentation from different sources, choose the earliest time. If there are two or more different symptomatic intracranial hemorrhage times (either different brain images or corresponding with the same brain image), enter the earliest time.
    • For times that include seconds, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00
    • If the time of symptomatic intracranial hemorrhage is unable to be determined from medical record documentation, select UTD.
    • The medical record must be abstracted as documented (taken at face value). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select UTD.
      Example:
      Documentation indicates primary brain image time was 3300. No other documentation in the medical record provides a valid time. Since primary brain image time is outside of the range listed in the Allowable Values for Hour, it is not a valid time and the abstractor should select UTD.
      Note: Transmission of a case with an invalid time as described above will be rejected from the Joint Commissions Data Warehouse. Use of UTD for Primary Brain Image Time allows the case to be accepted into the warehouse.

    Suggested Data Sources:

    • Diagnostic test reports
    • Brain imaging reports
    • Radiology reports

    Guidelines for Abstraction

    Inclusion: None

    Exclusion: None

    Summary of Changes

    OPTIONAL COMPREHENSIVE: Results of positive brain image

    For patients with documentation of a positive finding of intracranial hemorrhage, select the type of hemorrhage

    • PH2: Parenchymal Hematoma Type 2, defined by ECASS criteria as a hematoma occupying >30% of the infracted area accompanied by significant mass effect.
    • IVH: Intraventricular Hemorrhage
    • SAH: Subarachnoid Hemorrhage
    • RIH: Remote site of intraparenchymal hemorrhage outside the area of infarction
    • Other positive finding not listed above
    • None of the above or not documented

    Admission Data, Hospitalization Data, Radiology notes

    REQUIRED FOR COMPREHENSIVE: Is there documentation that a procoagulant reversal agent was initiated at this hospital?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Procoagulant Reversal Agent Initiation

    Collected For: CSTK-04

    Definition: A procoagulant reversal agent was initiated at this hospital. Procoagulant reversal agents are medications that increase coagulation factors to promote clotting.

    Suggested Data Collection Question: Is there documentation that a procoagulant reversal agent was initiated at this hospital?

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    Y (Yes) A procoagulant reversal agent was initiated at this hospital.

    N (No) A procoagulant reversal agent was not initiated at this hospital, OR unable to determine from medical record documentation.

    Notes for Abstraction:

    • If a procoagulant reversal agent was initiated at this hospital, select Yes.
    • Only accept reversal agents identified in the list of inclusions. No other terms for reversal agents will be accepted.
    • If Vitamin K only was administered as the sole form of reversal and no other procoagulant agent was administered, select No.

    Suggested Data Sources:

    • Emergency department record
    • Nursing flow sheet
    • Progress notes
    • Medication administration record (MAR)
    • Medication reconciliation form

    Guidelines for Abstraction

    Inclusion:

    • Activated prothrombin complex concentrates
    • Anti-inhibitor coagulant complex
    • Autoplex T
    • Bebulin VH
    • Eptacog alfa
    • Factor IX Complex
    • Factor VIIa (Recombinant)
    • Feiba VH Immuno
    • Fresh frozen plasma (FFP)
    • NovoSeven
    • NovoSeven RT
    • Profilnine SD
    • Proplex T
    • Prothrombin complex concentrates (PCCs)
    • rFVIIa
    • (Kcentra) PCC-Human
    • Pradaxa (dabigatran) reversal agent: Praxbind (idarucizumab)
    • Xarelto (rivaroxaban)/ Eliquis (apixaban) reversal agent: Andexxa (andexanet alfa)

    Exclusion:

    • Vitamin K Only
    • Factor IX (without complex)

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: Is there documentation by a physician/APN/PA or pharmacist in the medical record of a reason for not administering a procoagulant reversal agent?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Reason for Not Administering a Procoagulant Reversal Agent

    Collected For: CSTK-04

    Definition:

    Reason for not administering a procoagulant reversal agent.

    • Adverse reaction to a procoagulant reversal agent
    • Other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist.

    Procoagulant reversal agents are medications that increase coagulation factors to promote clotting.

    Suggested Data Collection Question: Is there documentation by a physician/APN/PA or pharmacist in the medical record of a reason for not administering a procoagulant reversal agent?

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    Y (Yes) There is documentation of a reason for not administering a procoagulant reversal agent.

    N (No) There is no documentation of a reason for not administering a procoagulant reversal agent OR unable to determine from medical record documentation.

    Notes for Abstraction:

    • Reasons for not administering a procoagulant reversal agent must be documented by the physician/APN/PA or pharmacist.
      • Physician/APN/PA or pharmacist documentation of a hold on a procoagulant reversal agent or discontinuation of a procoagulant reversal agent constitutes a ?#8364;œclearly implied?#8364;? reason for not administering the procoagulant reversal agent.
    • If reasons are not mentioned in the context of a procoagulant reversal agent, do not make inferences (e.g., do not assume that a procoagulant reversal agent was not administered because of an adverse reaction to a procoagulant reversal agent unless documentation explicitly states so.)
      • Reasons must be explicitly documented (e.g., "Allergic to cow milk. Do not give NovoSeven.")
    • When conflicting information is documented in the medical record, select "Yes".

    Suggested Data Sources:

    • Consultation notes
    • Emergency department record
    • History and physical
    • Progress notes
    • Discharge summary

    Guidelines for Abstraction

    Inclusion:

    • Patient/family refusal

    Exclusion: None

    Summary of Changes

    OPTIONAL COMPREHENSIVE: Date/Time procoagulant initiated

    Enter the Date/Time procoagulant therapy was initiated at this hospital. If patient receives multiple acceptable procoagulant therapies, enter the date that the first treatment was initiated.

    • Date:MM/DD/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    Admission Data, Hospitalization Data

    REQUIRED FOR COMPREHENSIVE: Is there documentation that nimodipine was administered at this hospital?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Nimodipine Administration

    Collected For: CSTK-06

    Definition: Documentation that nimodipine was administered at this hospital. Nimodipine is a cerebroselective calcium channel blocker that inhibits calcium transport into vascular smooth muscle cells, thereby suppressing contractions. Nimodipine is used in the treatment of subarachnoid hemorrhage patients to prevent or limit the severity of cerebral vasospasm.

    Suggested Data Collection Question: Is there documentation that nimodipine was administered at this hospital?

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    Y (Yes) Nimodipine was administered at this hospital.

    N (No) Nimodipine was not administered at this hospital,OR unable to determine from medical record documentation.

    Notes for Abstraction:

    • Nimodipine treatment must be administered at this hospital within the first 24 hours of arrival to select 'YES'. It is not necessary to review documentation outside of this timeframe.
    • If nimodipine was administered at another hospital and the patient was subsequently transferred to this hospital and nimodipine treatment continued on admission to this hospital, select ‘YES'
    • If nimodipine was administered at this hospital later than the first 24 hours after arrival, select 'NO'.
    • If nimodipine was administered at another hospital and the patient was subsequently transferred to this hospital and nimodipine treatment was not resumed or discontinued, select 'NO'.
    • A physician order for nimodipine that is not executed, select ‘NO'.

    Suggested Data Sources:

    • Emergency department record
    • Nursing flow sheet
    • Progress notes
    • Medication administration record (MAR)
    • Medical transport records
    • Medication reconciliation form

    Guidelines for Abstraction

    Inclusion:

    • Nimodipine
    • Nimotop
    • Nymalize

    Exclusion:

    • All other calcium channel blocker medications other than those listed as inclusions.

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: Is there documentation by a physician/APN/PA or pharmacist in the medical record of a reason for not administering nimodipine treatment?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Reason for Not Administering Nimodipine Treatment

    Collected For: CSTK-06

    Definition:

    Reason for not administering nimodipine treatment:

    • Nimodipine allergy
    • Non-aneurysmal subarachnoid hemorrhage (SAH)
    • Reversible cerebral vasoconstriction syndrome
    • Cerebral amyloid angiopathy
    • Other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist

    Nimodipine inhibits calcium transport into vascular smooth muscle cells, thereby preventing or limiting cerebral vasospasm.

    Suggested Data Collection Question: Is there documentation by a physician/APN/PA or pharmacist in the medical record of a reason for not administering nimodipine treatment?

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    Y (Yes) There is documentation of a reason for not administering nimodipine treatment.

    N (No) There is no documentation of a reason for not administering nimodipine treatment, OR unable to determine from medical record documentation.

    Notes for Abstraction:

    • Reasons for not administering nimodipine must be documented by the physician/APN/PA or pharmacist within 24 hours of hospital arrival. It is not necessary to review documentation outside of this timeframe.
    • The following are acceptable as stand-alone reasons for not administering nimodipine treatment – Nimodipine linkage is not needed:
      • Non-aneurysmal subarachnoid hemorrhage (SAH)
      • Reversible cerebral vasoconstriction syndrome
      • Cerebral amyloid angiopathy
    • If reasons are not mentioned in the context of nimodipine treatment, do not make inferences (e.g., do not assume that nimodipine was not administered because of hypotension unless documentation explicitly states so.)
      • Reasons must be explicitly documented (e.g., BP 80/40 No nimodipine.)
      • Physician/APN/PA or pharmacist documentation of a hold on nimodipine or discontinuation of nimodipine that occurs within the first 24 hours constitutes a clearly implied reason for not administering nimodipine treatment. A hold/discontinuation of all p.o. medications counts if nimodipine (i.e., Nimotop) was on order at the time of the notation.
        EXCEPTION:
        Documentation of a conditional hold or discontinuation of nimodipine (e.g., Hold nimodipine if SBP < 100 mm/Hg, Stop nimodipine if AST > 50 IU/L.)
    • When conflicting information is documented in the medical record, select Yes.
    • Documentation that the patient is NPO or has a nasogastric tube (NGT) without mention that nimodipine should not be administered is insufficient. Do not infer that nimodipine is not needed unless explicitly documented.
      • Physician orders for NPO except medications does not count as a reason for not administering nimodipine, select No.

    Suggested Data Sources:

    • Emergency department record
    • Nursing flow sheet
    • Progress notes
    • Medication administration record (MAR)
    • Medication reconciliation form

    Excluded Data Sources

    • Any documentation dated/timed later than 24 hours after hospital arrival.

    Guidelines for Abstraction

    Inclusion:

    • Patient/family refusal

    Exclusion: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: What is the date and time that nimodipine was first administered to this patient at this hospital?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Nimodipine Administration Date/Time

    Collected For: CSTK-06

    Definition: The month, date, year and time (military time) that the first dose of nimodipine was administered to a patient with subarachnoid hemorrhage at this hospital. Nimodipine inhibits calcium transport into vascular smooth muscle cells, thereby preventing or limiting cerebral vasospasm.

    Suggested Data Collection Question: What is the date and time that nimodipine was first administered to this patient at this hospital?

    Format

    Length:
    10 - MM-DD-YYYY (includes dashes) or UTD, 5 - HH-MM (with or without colon) or UTD
    Type: Date/Time
    Occurs: 1

    Allowable Values:

    MM = Month (01-12)
    DD = Day (01-31)
    YYYY = Year (2001-Current Year)
    UTD = Unable to Determine

    HH = Hour (00-23)
    MM = Minutes (00-59)
    UTD = Unable to Determine

    Notes for Abstraction:

    • Use the date at which administration of nimodipine was first documented. If a discrepancy exists in date documentation from different sources, choose the earliest date. If there are two or more different nimodipine administration dates (either different nimodipine episodes or corresponding with the same episode), enter the earliest date.
    • If the date nimodipine treatment was administered is unable to be determined from medical record documentation, select UTD.
    • The medical record must be abstracted as documented (taken at face value). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD.
      Example:
      Documentation indicates the nimodipine administration date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the nimodipine administration date is outside of the range listed in the Allowable Values for Day, it is not a valid date and the abstractor should select UTD.
      Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commissions Data Warehouse. Use of UTD for Nimodipine Administration Date allows the case to be accepted into the warehouse.
    • Use the time at which initiation of nimodipine administration was first documented. If a discrepancy exists in time documentation from different sources, choose the earliest time. If there are two or more different nimodipine administration times (either different nimodipine episodes or corresponding with the same episode), enter the earliest time.
    • For times that include seconds, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00
    • Nimodipine administration time refers to the time that the first dose of nimodipine was administered.
    • Do not use physician orders as they do not demonstrate administration of nimodipine treatment (in the ED this may be used if signed/initialed by a nurse).
    • If the time of nimodipine administration is unable to be determined from medical record documentation, select UTD.
    • The medical record must be abstracted as documented (taken at face value). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select UTD.
      Example:
      Documentation indicates the nimodipine administration time was 3300. No other documentation in the medical record provides a valid time. Since the nimodipine administration time is outside of the range listed in the Allowable Values for Hour, it is not a valid time and the abstractor should select UTD.
      Note: Transmission of a case with an invalid time as described above will be rejected from the Joint Commissions Data Warehouse. Use of UTD for Nimodipine Administration Time allows the case to be accepted into the warehouse.

    Suggested Data Sources:

    • Emergency department record
    • Nursing flow sheet
    • Progress notes
    • Medication administration record (MAR)
    • Medical transport records
    • Medical reconciliation form

    Guidelines for Abstraction

    Inclusion: None

    Exclusion: None

    Summary of Changes


    Other In-Hospital Treatments and Screening


    Patient NPO throughout the entire hospital stay?
    Was patient screened for dysphagia prior to any oral intake including water or medications?
    If yes, Dysphagia screening results:
    Treatment for Hospital-Acquired Pneumonia
    VTE Interventions
    Active bacterial or viral infection at admission or during hospitalization

    REQUIRED: Patient NPO throughout the entire hospital stay? 

    Indicate if the patient was NPO (nothing by mouth), including food, water, or medications, for the entire hospital stay. This includes any medications delivered in the Emergency Room phase of care.

    • Yes: The patient was kept NPO during the entire hospitalization and was discharged, transferred, or deceased NPO.
    • No/ND: The patient was not kept NPO during entire hospital stay or the patient received food, water or medication by mouth during the hospitalization (even if there was an NPO order).

    Notes for Abstraction:

    • Data abstractors should wait until either patient is taken off NPO or discharged prior to answering this question.
    • The delivery of food, fluid, or medication via a nasogastric tube, orogastric tube, or percutaneous gastrostomy tube should be independent of the assessment of NPO. "NPO except medications" is a commonly used order on patients who will be undergoing surgery or procedures in the near future to prevent the risk of peri-procedure complications. This order is used to limit the amount of material in the stomach prior to a procedure and is not relevant to the issue of dysphagia. "NPO except medications" is not an acceptable treatment order for patients who have not yet undergone dysphagia screening. Patient can be NPO and still receive delivery of food, fluid, or medication via a nasogastric tube (PNGT), orogastric tube (POGT), or percutaneous gastrostomy tube (PGT).
    • It is critical to review medication administration records from the ER to identify any oral medication received prior to the patient being made NPO or undergoing dysphagia screening, as this is a very common occurrence (for example "Aspirin 325mg POx1" prior to stroke team activation).
    • For inpatient stroke, assess NPO status from Date/Time of discovery of stroke symptoms? If the patient was made NPO prior to stroke symptom discovery and was kept NPO throughout the entire hospitalization select “Yes”.

    Admission Data, Hospitalization Data, especially Speech Pathology consultation or progress notes

    Summary of Changes

    REQUIRED: Was patient screened for dysphagia prior to any oral intake including water or medications?

    Stroke patients should be screened for dysphagia before being given any oral intake including food, fluids, or medications.

    • Yes: There is documentation of screening for dysphagia prior to any oral intake.
    • No/ND: There is either documentation of oral intake prior to screening for dysphagia or there is no documentation of screening for dysphagia.
    • NC: There are documented reasons for not performing a screening for dysphagia prior to any oral intake.

    Notes for Abstraction:

    • Documentation in the record should indicate that an assessment of the patient's ability to swallow was completed by a health care professional prior to oral intake of food, fluid, or medications. A screening test need not be a formal evaluation of swallowing by a speech and language pathologist, but should be a standardized method of swallowing assessment accepted by the institution.
    • A variety of methods may be employed to assess swallowing status. These methods may include but are not limited to:
      • Bedside swallow assessment
      • Simple water swallow test
      • Burke water swallow test
      • Bedside swallowing assessment
      • Simple standardized bedside swallowing assessment (SSA)
      • Barium swallow
      • Video fluoroscopy
      • Double contrast esophagoscopy
      • Radio nucleotide studies
      • Manometry
      • Endoscopy
      • Formal evaluation by speech language pathologist
    • If the patient was ONLY given sublingual (SL) medication specifically formulated for sublingual delivery (e.g., nitroglycerin) or traditionally given by sublingual route prior to dysphagia screen, this is not considered oral intake. These include medication formulations such as pills (e.g., lorazepam), orally disintegrating tablets (e.g., olanzipine) or wafers (e.g., clonazepam). If these sublingual medications are the only oral intake prior to dysphagia screen select “Yes”. If medications that are not traditionally given via the sublingual route are taken by the patient before dysphagia screening, then select the answer as “No/ND”.
    • The following are not acceptable as swallow screening:
      • Patient evaluation using the NIH/NIHSS (National Institute of Health/National Institute of Health Stroke Scale) is NOT considered dysphagia screening
      • Documentation of "Cranial nerves intact" is NOT considered dysphagia screening
      • Positive gag reflex noted
    • Reasons for not performing a dysphagia screen must be explicitly documented by a physician, advance practice nurse, or physician assistant. If reasons are not mentioned in the context of dysphagia screening, do not make inferences.
    • Acceptable reasons for not performing dysphagia screening include patient refused treatment, patients who are made CMO prior to receiving anything by mouth and patients with complete recovery of all symptoms and neurological deficits prior to hospital arrival (for these patients you may select the answer option of “NC” for this data element).
    • For inpatient stroke, assess dysphagia screen prior to oral intake from the date/time of discovery of stroke symptoms. If the patient arrives to the hospital with transient symptoms that resolve and was screened for dysphagia (prior to oral intake) but later in the hospital stay has new onset stroke symptoms and meets criteria to be entered as an inpatient stroke, a new dysphagia screen should be performed and dysphagia screen prior to oral intake should be assessed from the date/time stroke symptom discovery.

    Examples:

    • Patient 210a is admitted to the in-patient unit from the ED as NPO. The ED physician notes document evidence of dysphagia and a formal swallowing evaluation is ordered and performed. Data entry will be to check "Yes".
    • Patient 210b is admitted with dysarthria and drooling. The ED physician notes evidence of dysphagia and the diet order reads NPO except meds. No formal swallowing evaluation is performed. Data entry is "No/ND".
    • Patient 210c is admitted to the hospital on 4/1/2012 for heart failure. The patient is given PO food and medications. On 4/3/2012 the nurse discovers that the patient has difficulty speaking and facial droop and calls the stroke team. The stroke PA performs an NIHSS and dysphagia screen. The patient did not receive any food, water or medications from the date/time of discovery of stroke symptoms to the date/time that the dysphagia screen was performed. Data entry is to Select “Yes”.
    • Patient 210d arrives to the hospital on 3/22/2012 with transient symptoms that resolve in the ED prior to admission. The patient had a dysphagia screen in the ED prior to oral intake. The patient is admitted to the stroke unit. Later that day nurse discovered that the patient developed new onset right sided-weakness. The nurse activates the stroke team and when the stroke physician arrives, the patient is eating dinner. The nurse did not do a repeat dysphagia screen. Data entry is to Select “No/ND.” Note, this patient would be entered as an inpatient stroke.

    Admission Data, Hospitalization Data, especially Speech Pathology consultation or progress notes

    Summary of Changes

    REQUIRED FOR COVERDELL: If yes, Dysphagia screening results:

    If dysphagia screening occurred prior to oral intake, select result of the initial screen:

    • Pass
    • Fail
    • ND

    Notes for Abstraction:

    • Select "Pass" if there is documentation that the screen is passed, or that the patient successfully demonstrates safe swallowing on the initial bedside screening evaluation. Do not record the results of subsequent dysphagia screenings. Documentation might include evidence that oral intake of food or medication without modification of consistency or other swallowing related features is permitted unsupervised. Restrictions on type of diet such as amounts of calories, protein, etc are not relevant to this item.
    • Select "Fail" if there is documentation that the screen is failed, or that the patient did not demonstrate safe swallowing on dysphagia screening protocol. Restrictions in oral intake generally follow as a result of failure in screen.
    • Select "ND" if there was a screen performed but there is no documentation as to the results of the dysphagia screen.

    Admission Data, Hospitalization Data, especially Speech Pathology consultation or progress notes

    Summary of Changes

    OPTIONAL: Treatment for Hospital-Acquired Pneumonia (Was the patient treated for pneumonia during this admission?)

    Indicate if patient was treated for nosocomial (hospital-acquired) pneumonia after 48 hours of admission.

    • Yes: There is clinical mention of hospital-acquired pneumonia by the physician, and treatment with an antibiotic for pneumonia.
    • No: There is clinical mention of hospital-acquired pneumonia by the physician, but treatment with an antibiotic was not prescribed.
    • NC

    Notes for Abstraction:

    • Documentation does not need to include the words “hospital acquired.” Classification of hospital acquired pneumonia can be accomplished by determining if there is clinical suspicion or mention of pneumonia in the medical record 48 or more hours after admission and then determining if pneumonia or clinical suspicion of pneumonia was documented on hospital admission. If there is no mention of pneumonia on admission, it is considered hospital acquired pneumonia.
    • The intent of this data element is to determine if there is clinical mention of pneumonia 48 or more hours after admission AND if subsequent treatment for pneumonia was administered. If there is clinical mention of pneumonia 48 or more hours after admission, but NO treatment with antibiotic, select “No”

    Example: Patient 220a is admitted with stroke symptoms and started on an oral diet after passing a dysphagia screen. A chest X-ray from day 2 describes "pneumonia vs. atlectasis." This is mentioned in the physician notes but the decision is made to treat for congestive heart failure and wait for a fever before starting antibiotics. No antibiotics are subsequently given. Since a diagnosis of pneumonia was not made, select "NC".

    Admission Data, Hospitalization Data, especially Speech Pathology consultation or progress notes

    Summary of Changes

    REQUIRED and REQUIRED FOR COVERDELL: VTE Interventions

    Please Note: As this is a data element that is shared by GWTG, TJC, and Coverdell the definition below comes directly from the Specifications Manual for National Hospital Inpatient Quality measures. This VTE interventions list only contains medications and devices that are FDA approved for VTE prophylaxis (items 1-8). If a patient is receiving therapeutic anticoagulation for an indication other than prophylaxis (i.e. full dose IV heparin or an alternate anticoagulant such as dabigatran) and is not receiving any interventions on this list, select “A – None of the above or not documented or unable to determine from medical record documentation” here and then select the appropriate medication from the “Other Therapeutic Anticoagulation” list. If a patient is receiving Rivaroxaban (Xarelto) and is not receiving any other medication on this list, select 8-Oral factor Xa inhibitor here and also select Rivaroxaban (Xarelto) under the “Other Therapeutic Anticoagulation” list. If a patient is receiving Apixaban (Eliquis) and is not receiving any other medication on this list, select 8-Oral factor Xa inhibitor here and also select Apixaban (Eliquis) under the “Other Therapeutic Anticoagulation” list. If a patient is receiving treatment with an intervention on this VTE interventions list and is also receiving an alternate anticoagulant, just select the appropriate interventions from the “VTE Interventions” list.

    Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

    The type of venous thromboembolism (VTE) prophylaxis documented in the medical record:

    1. 1- Low dose unfractionated heparin (LDUH)
    2. 2- Low molecular weight heparin (LMWH)
    3. 3- Intermittent pneumatic compression devices (IPC)
    4. 5- Factor Xa Inhibitor
    5. 6- Warfarin
    6. 7- Venous foot pumps (VFP)
    7. 8- Oral Factor Xa Inhibitor
    8. A- None of the above or not documented or unable to determine from medical records documentation

      Notes for Abstraction:

      • No value should be selected more than once. If a value of "A" is selected, no other selection should be recorded.
        Example:
        Lovenox is ordered and substituted with dalteparin. Only abstract value "2" once, as both are LMWH.
      • Application of mechanical prophylaxis may be documented by any personnel.
        Example:
        Nursing assistant documentation of IPC application during the allowable timeframe is acceptable.
      • Selection of allowable values 1-8 includes any prophylaxis that was initially administered in the allowable time frame.
        Example:
        If a patient was admitted on 12/8/20xx and had IPCs applied at 13:00 on 12/09/20xx and LMWH was administered at 22:00 on 12/8/20xx, select values “2” and “3”.
      • Only select prophylaxis if there is documentation that it was administered. Documentation in the physician progress notes under assessment/Plan: “DVT prophylaxis – IPC” is not enough to select Value “3.”
      • If one pharmacological medication is ordered and another medication is substituted (such as per pharmacy formulary substitution or protocol), abstract the medication administered.
        Note: No copy of the formulary or protocol is required in the medical record.
        Example:
        Lovenox is ordered, but not received and is substituted with fondaparinux sodium, which is received by the patient. Abstract fondaparinux sodium as Value “5” for VTE Prophylaxis and abstract the date it was administered for VTE Prophylaxis Date.
      • Abstract ALL VTE prophylaxis(s) that was administered the day of or the day after hospital admission. If no VTE prophylaxis was administered during this timeframe, select "A."
      • VTE Prophylaxis administered in the ED or Observation prior to the hospital admission order is not sufficient.

    Suggested Data Sources:

    PHARMACOLOGICAL AND MECHANICAL

    • Emergency department record
    • Graphic/flow sheets
    • Medication administration record
    • Nursing notes
    • Physician notes
    • Progress notes

    Inclusion Guidelines for Abstraction: Refer to Appendix H, Table 2.1 VTE Prophylaxis Inclusion Table.

    Exclusion Guidelines for Abstraction: None

    Admission Data, Hospitalization Data

    Summary of Changes

    REQUIRED and REQUIRED FOR COVERDELL: What date was the VTE prophylaxis administered?

    Please Note: As this is a data element that is shared by GWTG, TJC, and Coverdell the definition below comes directly from the Specifications Manual for National Hospital Inpatient Quality Measures.

    Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

    The day, month and year that VTE prophylaxis (mechanical and/or pharmacologic) was administered after hospital admission.

    • MM = Month (1-12)
    • DD = Day (01-31)
    • YYYY = Year (20xx)
    • UTD = Unable to Determine

    Notes for Abstraction:

    STK

    • The earliest date associated with a form of prophylaxis should be entered.
      Example:
      If the patient was admitted on 12-08-20xx and IPCs were applied at 13:00 on 12-08-20xx and LMWH was administered at 02:00 on 12-09-20xx, record the 12-08-20xx date.

    STK or VTE

    • The medical record must be abstracted as documented (taken at “face value”). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select “UTD”.
      Example:
      Documentation indicates the VTE Prophylaxis Date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the VTE Prophylaxis Date is outside of the range listed in the Allowable Values for “Day,” it is not a valid date and the abstractor should select “UTD”.
      Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commission’s Data Warehouse. Use of “UTD” for VTE Prophylaxis Date allows the case to be accepted into the warehouses.”

    Suggested Data Sources:

    • Graphic/flow sheets
    • Medication administration record
    • Nursing notes
    • Physician notes
    • Progress notes

    Inclusion Guidelines for Abstraction: None

    Exclusion Guidelines for Abstraction: None

    REQUIRED FOR TJC if VTE Interventions is 4 or A: Is there physician/APN/PA or pharmacist documentation why VTE prophylaxis was not administered at hospital admission?

    Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

    Data Element Name: Reason for No VTE Prophylaxis ?#8364;“ Hospital Admission

    Collected For: STK-01

    Definition: Physician/APN/PA or pharmacist documentation why mechanical AND pharmacological VTE prophylaxis was not administered at hospital admission.

    • Explicit documentation of a contraindication to BOTH mechanical prophylaxis AND pharmacological prophylaxis is needed.
    • Yes: there is physician/APN/PA or pharmacist documentation why VTE prophylaxis was not administered at hospital admission. 
    • No: there is no physician/APN/PA or pharmacist documentation why VTE prophylaxis was not administered at hospital admission or unable to determine from medical record documentation.  

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    Y (Yes) There is physician/APN/PA or pharmacist documentation why VTE prophylaxis was not administered at hospital admission.

    N (No) There is no physician/APN/PA or pharmacist documentation why VTE prophylaxis was not administered at hospital admission or unable to determine from medical record documentation.

    Notes for Abstraction:

    • If a patient received prophylaxis as per the data element VTE Prophylaxis, select "No."
    • To select "Yes" for this data element, documentation must be dated from arrival to the day after hospital admission or surgery end date. Documentation written after arrival but prior to admission is acceptable.
    • Reasons for not prescribing mechanical and pharmacological VTE prophylaxis must be documented by a physician/APN/PA or pharmacist.
      Exceptions:
      • Patient/family refusal may be documented by a nurse, but should be documented within the same time frame as the reason for no VTE prophylaxis. Patient/family refusal of any form of prophylaxis is acceptable.
        Example:
        Patient refused heparin, select “Yes.”
    • For patients on anticoagulants:
      • For patients on continuous IV heparin therapy the day of or day after hospital admission, select “Yes.”
      • If warfarin is listed as a home or current medication, select “Yes” regardless of other documentation.
      • For patients receiving anticoagulant therapy for atrial fibrillation or for other conditions (e.g. angioplasty), with anticoagulation administered on the day of or the day after hospital admission, select “Yes.”
    • If reasons are not mentioned in the context of VTE prophylaxis, do not make inferences (e.g., do not assume that VTE Prophylaxis was not administered because of a bleeding disorder unless documentation explicitly states so).
      Example:
      • Physician/APN/PA or pharmacist documentation of bleeding risk, review the chart for documentation about reasons for no mechanical AND reasons for no pharmacological VTE prophylaxis.
    • EXCEPTION:
      • Documentation within the timeframe specified that the patient is a bilateral lower extremity amputee is an acceptable reason for no mechanical prophylaxis.
    • Physician/APN/PA or pharmacist documentation that the patient is ambulating without mention of VTE prophylaxis is insufficient. Do not infer that VTE prophylaxis is not needed unless explicitly documented.
      Examples:
      • There is documentation of “No VTE Prophylaxis, patient ambulating,” select “Yes.”
      • There is documentation of “Patient low risk for VTE, ambulating,” select “Yes.”
    • For patients with a reason for no pharmacologic or no mechanical prophylaxis and an order for ANY prophylaxis that was NOT administered without a reason, select “No.”
      Example:
      • Patient has documentation of an order for IPCs and no documentation that IPCs were applied, select “No.
    • If two physicians/APN/PA or pharmacists document conflicting or questionable risk/needs for prophylaxis, select “No.”
    • If a risk assessment is used, and notes anything other than low risk (e.g. intermediate risk, moderate risk, or high risk), additional documentation must be present to answer “Yes.” Explicit documentation of a contraindication to mechanical AND contraindication to pharmacological prophylaxis must be addressed.
      • If there is physician documentation of “bleeding, no pharmacologic prophylaxis” the chart must be reviewed for documentation about a reason for no mechanical prophylaxis in order to select “Yes.”
        Examples:
        • Bleeding, no pharmacologic prophylaxis, no mechanical prophylaxis.
        • Active GI bleed – low molecular weight heparin contraindicated, no mechanical prophylaxis needed.
        • "No VTE Prophylaxis", "No VTE Prophylaxis needed" [no reason given].
    • If Comfort Measures Only (CMO) was documented after the day after arrival (Day 1) but by the day after hospital admission, select “Yes.”
      Example:
      • Patient arrives in the ED on 06/01/20xx but is in observation until admission to the hospital on 06/03/20xx. If CMO is documented by 06/04/20xx, select “Yes.”
    • Documentation that the patient is adequately anticoagulated or already anticoagulated on warfarin, select “Yes.”
      Examples:
      • Patient is already anticoagulated, taking Coumadin at home prior to admission.
      • INR therapeutic and adequately anticoagulated at this time.
    • Documentation synonymous with “abruptly reversed anticoagulation for major bleeding,” select “Yes.”
      Examples:
      • INR reversal for major bleeding.
      • Reverse anticoagulation for intracranial hemorrhage.
    • Documentation of administration of IV alteplase is NOT a stand-alone reason for no VTE prophylaxis.

    SUGGESTED DATA SOURCES:
    ONLY PHYSICIAN/APN/PA OR PHARMACIST DOCUMENTATION OF A REASON FOR NOT ADMINISTERING VTE PROPHYLAXIS:

    • Consultation notes
    • Emergency Department record
    • History and physical
    • Physician orders
    • Physician progress notes
    • Risk assessment form
    • Transfer form
    • Medication administration record
    • Nurses notes
    • Risk Assessment

    Additional Notes: None

    Guidelines for Abstraction:

    Inclusion

    Exclusion

    None

    Refer to Appendix H, Table 2.7 Anticoagulation Therapy for Atrial Fibrillation and Other Conditions.

    • Unchecked checkbox next to a reason (e.g., blank checkbox on a form or electronic template next to “cogulapathy” or “bilateral amputee”).
    • Checked checkbox next to "other reason" with a blank space for the specific reason

     Summary of Changes

    Is there physician/APN/PA or pharmacist documentation why Oral Factor Xa Inhibitor was administered for VTE prophylaxis?

    For discharges on or after 01/01/2013

    Collected For: STK-1

    Definition: Documentation why Oral Factor Xa was administered for VTE prophylaxis

    Question: Is there physician/APN/PA documentation why Oral Factor Xa was administered for VTE prophylaxis?

    Format: Single Select

    Allowable Values:

    • Yes
    • No

    Notes of Abstraction:

    • Yes - There is physician/APN/PA or pharmacist documentation why Oral Factor XA Inhibitor was administered for VTE Prophylaxis.
    • No - There is no physician/APN/PA or pharmacist documentation why Oral Factor XA Inhibitor was administered for VTE Prophylaxis.
    • The only acceptable reasons are identified in the list of inclusions. No other reasons will be accepted.
    • History of atrial fibrillation/flutter or current finding of atrial fibrillation/flutter, select “Yes”.
    • If the patient has a history of previous strokes and/or taking an Oral Factor Xa Inhibitor prior to hospital arrival, select "Yes".
    • History of hip or knee replacement surgery, select “Yes”.
    • When conflicting information is documented in the medical record, select “Yes”.
    • History of treatment of venous thromboembolism or current treatment for venous thromboembolism, select “Yes”.
    • Physician/APN/PA or pharmacist documentation only for the following acceptable sources:
      • Anesthesia Record
      • Consultation Notes
      • Emergency Department Record
      • History and Physical
      • Operative Note
      • Physician Orders
      • Progress Notes
      • Risk Assessment Form
      • Transfer Sheet

    Additional Notes / Guidelines for Abstraction:

    • Inclusion
      • AF
      • A-Fib
      • Atrial Fibrillation
      • Atrial flutter
      • History of any remote episode of documented atrial fibrillation or flutter except within 8 weeks following CABG
      • PAF
      • Paraoxysmal atrial fibrillation
      • Partial hip arthroplasty
      • Partial hip replacement
      • Persistent atrial fibrillation
      • Stroke prevention / history of stroke
      • THR
      • TKR
      • Total hip arthroplasty
      • Total hip replacement
      • Total knee arthroplasty
      • Total knee replacement
      • Treatment of venous thromboembolism
    • Exclusion:
      • Atrial flutter
      • History of any remote episode of documented atrial fibrillation or flutter except within 8 weeks following CABG
      • PAF
      • Paraoxysmal atrial fibrillation
      • Partial hip arthroplasty
      • Partial hip replacement
      • Persistent atrial fibrillation
      • Stroke prevention / history of stroke
      • THR
      • TKR
      • Total hip arthroplasty
      • Total hip replacement
      • Total knee arthroplasty
      • Total knee replacement
      • Treatment of venous thromboembolism

    OPTIONAL: Other Therapeutic Anticoagulation

    If patient did not receive one of the listed “VTE Interventions” 1-7 but was receiving therapeutic anticoagulation therapy by the end of the day after hospital admission for an indication other than VTE prophylaxis, or if the patient was receiving an Oral Factor Xa Inhibitor, select the medication received.

    • Unfractionated heparin IV
    • Dabigatran (Pradaxa)
    • Argatroban
    • Desirudin (Iprivask)
    • Rivaroxaban (Xarelto)
    • Apixaban (Eliquis)
    • Lepirudin (Refludan)
    • Other Anticoagulant

    Examples:

    Patient 240d arrives at ED on Monday at 05:00 with an ischemic stroke. He is started on continuous IV heparin at 7:00. Pneumoboots are prescribed and initiated the following morning. Select “VTE Interventions = Intermittent pneumatic compression devices (IPC)”. Since this patient is already on IPC, the “Other Therapeutic Anticoagulation” section will be grayed out and you will not need to enter that the patient received IV Heparin in this section.

     

    Summary of Changes

    REQUIRED FOR COVERDELL: Was DVT or PE documented? (Was evidence of DVT or PE (pulmonary embolus) documented?)

    Indicate if evidence of DVT or PE was documented in the medical record. This question refers to the in-hospital development of DVT or PE. Pre-existing DVT or PE prior to admission should not be counted.

    • Yes
    • No/ND

    The documentation of DVT or PE must be confirmed by ultrasound, venous imaging or appropriate diagnostic modality. [The Joint Commission defines this as objectively confirmed DVT based on duplex ultrasound, contrast venography, CT with contrast or CT venogram, MR imaging or MR venography]. Insure that the report clearly indicates that a deep vein, and not a superficial vein, is involved.

    Examples:

    • Patient 250a was prescribed DVT prophylaxis on admission to hospital for ischemic stroke. On day 4 of admission the patient had a tender calf, ultrasound revealed a DVT of the left calf. Answer would be "Yes".
    • Patient 250b was prescribed DVT prophylaxis on admission to hospital for ischemic stroke. On day 4 of admission the patient had a tender calf, ultrasound was negative for DVT. Answer would be "No/ND".
    • Patient 250c was prescribed DVT prophylaxis on admission to hospital for ischemic stroke. On the day of admission, the patient complained of a tender calf for the previous 3 days. Ultrasound revealed a DVT of the left calf. Answer would be "No/ND".
    • Patient 250d was prescribed DVT prophylaxis on admission to hospital for ischemic stroke. There is no documentation about imaging studies performed to identify DVT. Answer would be "No/ND".

    Admission Data, Hospitalization Data

    Summary of Changes

    REQUIRED: Was antithrombotic therapy administered by the end of hospital day 2?

    Note for Stroke Core Measure/TJC users: This field autopopulates "Was antithrombotic therapy administered by the end of hospital day 2?" in the Core Measure tab. Verify that the antithrombotic medication is acceptable for TJC stroke core measures by checking Appendix C Table 8.2 in the most current specifications manual. If the medication administered does not appear in Table 8.2, you must change the autopopulated response in the Core Measure Tab to "Was antithrombotic therapy administered by the end of hospital day 2?" to "No" in order to be compliant with TJC standards.

    Collected For: ASR-IP-2, ASR-OP-2, STK-5

    Definition: Documentation that antithrombotic therapy was admistered by the end of hospital day 2. Antithrombotics include both anticoagulant and antiplatelet drugs.

    Suggested Data Collection Question: Was antithrombotic therapy administered by the end of hospital day 2?

    • Yes: Antithrombotic therapy was administered by the end of hospital day 2.
    • No/ND: Antithrombotic therapy was not administered by the end of hospital day 2, OR unable to determine from medical record documentation.
    • NC: There is documentation in the medical record of a reason for not administering antithrombotic therapy by end of hospital day 2.

    Notes for Abstraction:

    • Refer to Table 4 and Table 5 for acceptable antithrombotic therapy.Antithrombotics include both anticoagulant and antiplatelet drugs.
    • To compute end of Hospital Day two, count the day of arrival at this hospital as day one. If antithrombotic therapy was administered by 11:59 PM of hospital day two, answer “Yes” for this data element.It is not necessary to review documentation outside of this timeframe to answer this data element.
      • Examples:
        • Patient arrives in ED on Monday 05:00, antithrombotic therapy must be initiated before 23:59 on Tuesday;
        • Patient arrives at 23:30 on Monday antithrombotic therapy must be initiated by 23:59 on Tuesday.
    • For antithrombotic therapy administered in the Emergency Department/observation area prior to the end of hospital day 2, select “Yes”.
    • Antithrombotic therapy administration information must demonstrate actual administration of the medication.
      • Example: Do not use physician orders as they do not demonstrate administration of the antithrombotic therapy (in the ED this may be used if signed/initialed by a nurse).
    • When antithrombotic is noted as a “home” or “current” medication or documentation indicates that it was received prior to hospital arrival only, select “No”.
    • Lovenox SQ for VTE prophylaxis (i.e. enoxaparin SQ 40 mg once daily; enoxaparin SQ 30 mg Q12 hours) is not sufficient. If no other antithrombotic therapy is administered by the end of the hospital day 2, select "No."
    • Reasons for not prescribing antithrombotic medication must be documented by a physician, advance practice nurse or physician assistant (with one exception: Patient/family refusal does not have to be documented by a physician/APN/PA or pharmacist but it must be documented in the timeframe of arrival to the end of hospital day 2.).
    • If reasons are not mentioned in the context of antithrombotics, do not make inferences (e.g., do not assume that antithrombotic medication is not being prescribed because of a bleeding disorder unless documentation explicitly states so).
    • Documentation for allowable value “NC” must be found within the timeframe of arrival to the end of hospital day 2. It is not necessary to review documentation outside of this timeframe to answer this data element.
    • An allergy or adverse reaction to one type of antithrombotic would NOT be a reason for not administering all antithrombotics. Another medication can be ordered.
    • Orders to hold antithrombotic therapy without a documented reason is NOT acceptable to select “NC”.
    • Physician/APN/PA or pharmacist documentation of a hold on an antithrombotic medication or discontinuation of an antithrombotic medication that occurs the day of or day after hospital arrival constitutes a “clearly implied” reason for not administering antithrombotic therapy by end of hospital day 2. A hold/discontinuation of all p.o. medications counts if an antithrombotic was on order at the time of the notation.
    • For patients on warfarin therapy prior to hospital arrival, but placed on hold the day of or after arrival due to “high INR”, select “Yes”.
    • Acceptable reasons for not giving antithrombotic medication by the end of the 2nd hospital day include:
      • Allergy to or complication related to antithrombotic
      • Aortic dissection
      • Bleeding disorder
      • Brain/CNS cancer
      • CVA, hemorrhagic
      • Extensive/metastatic CA
      • Hemorrhage, any type
      • Intracranial surgery/biopsy
      • Patient/family refusal
      • Peptic ulcer
      • Planned surgery within 7 days following discharge
      • Risk of bleeding or discontinued due to bleeding
      • Serious side effect to medication
      • Unrepaired intracranial aneurysm
      • Terminal Illness
      • Other documented by physician/APN/PA or pharmacist
    • If antithrombotic held for 24 hours due to status post IV alteplase, select “NC”.
    • For inpatient stroke, to compute end of Hospital Day two, count the day of stroke symptom discovery as day one. If antithrombotic therapy was administered by 11:59 PM of the day after stroke symptom disc very, answer “Yes” for this data element. If the patient was re ceiving antithrombotic therapy prior to date/time stroke discovery you still need to assess whether the patient was receiving antithrombo tic therapy by the second hospital day after the discovery of stroke symptoms.

    Admission Data, Hospitalization Data, Emergency department record, Nursing notes, Nusing flow sheet, Progress notes, Physician ordres, Medication administration record (MAR)

    Excluded Data Sources

    • Emergency medical system (EMS) or ambulance documentation.
    • Any documentation dated/timed prior to hospital arrival or after hospital day 2

    Additional Notes:

    Guidelines for Abstraction:

    Inclusion

    • Refer to Appendix C, Table 8.2 for a list of medications used for antithrombotic therapy.

    Exclusion

    • Heparin Flush
    • Heparin SQ
    • Hep-Lock

    Summary of Changes

    OPTIONAL: If yes, Select all that apply

    If antithrombotic therapy was administered by the end of hospital day 2, indicate whether an antiplatelet and/or anticoagulant was administered.

      • Antiplatelet: See Table 4 for a list of antiplatelet medications.
      • Anticoagulant: See Table 5 for a list of anticoagulant medications.

    Summary of Changes

    OPTIONAL FOR COVERDELL ONLY: Was patient treated for a urinary tract infection (UTI) during this admission?

    Indicate if patient was treated for hospital-acquired urinary tract infection that developed following admission.

    • Yes
    • No/ND

    Select Yes if there was clinical mention of UTI by the physician, and treatment with an antibiotic for UTI. Select No/ND if there was clinical mention of UTI by the physician, but treatment with an antibiotic was not prescribed, or if there is no clinical mention of UTI.

    Admission Data, Hospitalization Data

    Summary of Changes

    OPTIONAL FOR COVERDELL ONLY: If patient was treated for a UTI, did the patient have a Foley catheter during this admission?

    Indicate if the patient had a Foley catheter during this admission.

    • Yes, patient had catheter in place on arrival
    • Yes, but only after admission
    • No
    • Unable to determine

    For the Foley catheter, if the patient had a catheter in place prior to the event/admission select choice 1. If patient did not arrive with a catheter in place, but required a Foley after admission, select 2. If patient had a condom catheter only, select No.

    Admission Data, Hospitalization Data

    Active bacterial or viral infection at admission during hospitalization

    Definition: Documentation that the patient had an active bacterial or viral infection at admission or during this hospitalization.

    Question: Was there an active bacterial or viral infection at admission or during hospitalization?

    Format: Multi-Select

    Allowable Values:

    • None
    • Bacterial Infection
    • Emerging Infectious Disease
      • SARS-COV-1
      • SARS-COV-2 (COVID-19)
      • MERS
      • Other Emerging Infectious Disease
    • Influenza
    • Seasonal cold
    • Other viral infection

    Notes for Abstraction:

    • Select Emerging Infectious Disease when the patient is known to have:
      • SARS-COV-1 (Severe Acute Respiratory Syndrome-associated coronavirus) - May include ICD-10- CM code B97.21
      • SARS-COV-2 (COVID-19) (Severe Acute Respiratory Syndrome-associated coronavirus) - May include ICD-10-CM code U07.1
      • MERS (Middle East Respiratory Syndrome) - May include ICD-10-CM code B97.29
    • Select one of the allowable values only when a confirmed diagnosis is documented by the provider or when a positive test result is documented in the patient medical record.
      • SARS-COV-1 or SARS-COV-2: A confirmed diagnosis includes a positive RT-PCR test, a positive IgM antibody test, or a clinical diagnosis using hospital specific criteria.
      • Influenza: A confirmed diagnosis includes a positive rapid AG or positive PCR test
    • Do not select if the documentation states only "suspected", "possible", "probable" or "inconclusive" infection.
    • Select None if no bacterial or viral infection was documented.

    Suggested Data Sources:

  • Admission Data
  • Hospitalization Data
  • Additional Notes / Guidelines for Abstraction: N/A


    Advanced Stroke Care



    General Information:
    The purpose of the endovascular thrombectomy (EVT) data elements in this tab is to capture patients ages 18 years and older who have a diagnosis of acute ischemic stroke and were treated with a reperfusion therapy – either IV or IA thrombolytic therapy or mechanical endovascular reperfusion therapy.

    Note: The tab will appear for sites that have enabled the tab or are submitting data to TJC for CSTK. Please note that fields that contain an asterisk(^) are required TJC fields. The CSTK data elements will only be enabled if the patient included in the initial patient population per TJC algorithm. Otherwise, the field will remain grayed out.

    To enable/ disable the Advanced Stroke Care tab, follow the steps outlined below:
    1. Logon to the GWTG - Stroke module
    2. On the Community Page, select the Update Stroke Site Characteristics
    3. On the organization form, scroll to the bottom of the page
    4. Under Settings (last section), respond to the following question: Mechanical endovascular reperfusion procedures for acute stroke are performed at my hospital? By selecting the YES option.
      1. To disable, select the NO option.
    5. Select the Save Changes button.


    Endovascular Stroke Treatment

    REQUIRED FOR COMPREHENSIVE: Is there documentation that the route of thrombolytic (alteplase) administration was intra-arterial (IA)?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: IA Route of alteplase Administration

    Collected For: CSTK-05, CSTK-07, CSTK-08, CSTK-09

    Definition: The route of thrombolytic (alteplase) administration was intra-arterial (IA). Thrombolytic therapy may be administered intra-venously (IV) by infusion directly into a vein through a peripheral or central venous catheter, or it may be given through an endovascular mircrocatheter delivery system positioned in an artery to directly infuse alteplase into the clot.

    Suggested Data Collection Question: Is there documentation that the route of thrombolytic (alteplase) administration was intra-arterial (IA)?

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    Y (Yes) The route of alteplase administration was intra-arterial (IA).

    N (No) The route of alteplase administration was not intra-arterial (IA), OR unable to determine from medical record documentation.

    Notes for Abstraction:

    • If the route of thrombolytic administration is documented as intra-arterial (IA), select "Yes"
    • If both intravenous (IV) and intra-arterial (IA) thrombolysis are given either in different procedures or the same procedure, select "Yes".
      Examples:
      • "IV alteplase given at hospital 'A' prior to transfer to hospital 'B' (i.e. drip and ship). Mechanical thrombectomy with IA thrombolysis was performed at hospital 'B'".
      • "NIHSS score 3 on arrival to this hospital. IV alteplase initiated in ED with initial improvement noted and NIHSS score zero post-infusion. NIHSS score 5 one hour later. Patient taken to interventional suite and IA alteplase administered."
    • If the only route of thrombolytic administration was intra-venous (IV) at this hospital or a transferring hospital, select "No".
    • If IA thrombolytic was administered at another hospital and the patient subsequently transferred to this hospital, select "No".

    Suggested Data Sources:

    ONLY acceptable data source

    • Consultation notes
    • Diagnostic test reports
    • Operative notes
    • Procedure notes

    Guidelines for Abstraction

    Inclusion:

    Only Acceptable Thrombolytic Therapy for Stroke

    • Activase
    • Alteplase
    • IA alteplase
    • Recombinant Tissue Plasminogen Activator (rt-PA)
    • Tissue plasminogen Activator (t-PA)

    Exclusion:

    • Intravenous (IV) alteplase (t-PA)
    • IA administration of thrombolytic agents not listed as inclusions

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: Is there documentation that IA thrombolytic therapy was initiated at this hospital?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: IA Thrombolytic Initiation

    Collected For: CSTK-07

    Definition: Intra-arterial (IA) thrombolytic therapy was initiated at this hospital. IA thrombolytics convert plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving thrombus.

    Suggested Data Collection Question: Is there documentation that IA thrombolytic therapy was initiated at this hospital?

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    Y (Yes) IA thrombolytic was initiated at this hospital.

    N (No) IA thrombolytic was not initiated at this hospital, OR unable to determine from medical record documentation.

    Notes for Abstraction:

    • When a "start time" or "infusion time" for IA thrombolytic is documented in the medical record, select "Yes".
    • If the data element "IA Route of alteplase Administration" is "Yes", select "Yes" for this data element.
    • If IA thrombolytic initiation is unable to be determined from medical record documentation, select "No".
    • If IA thrombolytic was administered at another hospital and the patient subsequently transferred to this hospital, select "No".

    Suggested Data Sources:

    ONLY acceptable data source

    • Consultation notes
    • Diagnostic test reports
    • Operative notes
    • Procedure notes

    Guidelines for Abstraction

    Inclusion:

    Only Acceptable Thrombolytic Therapy for Stroke

    • Activase
    • Alteplase
    • IA alteplase
    • Recombinant Tissue Plasminogen Activator (rt-PA)

    Exclusion:

    • Intravenous (IV) alteplase
    • IA administration of thrombolytic agents not listed as inclusions

    Summary of Changes

    What is the date and time that IA thrombolytic therapy was initiated for this patient at this hospital?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: IA Thrombolytic Initiation Date, IA Thrombolytic Initiation Time

    Definition: The date associated with the time that Intra-arterial (IA) thrombolytic therapy was initiated to a patient with ischemic stroke at this hospital. IA thrombolytics convert plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving thrombus.

    Data Collection Question: What is the date associated with the time that IA thrombolytic therapy was initiated for this patient at his hospital?


    Format:

    Length: 10 - MM-DD-YYYY (includes dashes) or UTD

    Type: Date

    Occurs: 1

    Allowable Values:

    MM = Month (01-12)

    DD = Day (01-31)

    YYYY = Year (2001-Current Year)

    UTD = Unable to Determine

    Notes for Abstraction:

    • If the date IA alteplase or MER was initiated is unable to be determined from medical record documentation, select UTD.

    • The medical record must be abstracted as documented (taken at "face value"). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD.

      Example:

      Documentation indicates the MER initiation date as 03-42-20xx. No other documentation in the medical record provides a valid date. Since the MER initiation date is outside of the range listed in the allowable Values for Day, it is not a valid date and the abstractor should select UTD.

      Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commission's Data Warehouse. Use of "UTD" for IA alteplase or Mer Initiation Date allows the case to be accepted into the warehouse.



    Suggested Data Sources:

    • Consultation notes

    • Procedure Notes

    • Operative notes

    • Diagnostic test reports



    Additional Notes:



    Guidelines for Abstraction: No exclusion

    REQUIRED FOR COMPREHENSIVE: Is there documentation in the medical record that the first endovascular treatment procedure was initiated greater than 8 hours after arrival at this hospital?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Delayed Endovascular Rescue Procedure

    Collected For: CSTK-09, CSTK-11

    Definition: Endovascular treatment (EVT) with a device and/or intra-arterial (IA) thrombolysis (alteplase) that was first performed at this hospital later than 8 hours after hospital arrival.

    Suggested Data Collection Question: Is there documentation in the medical record that the first endovascular treatment procedure was initiated greater than 8 hours after arrival at this hospital?

    Format:

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:


    Y (Yes)There is documentation that the first endovascular treatment procedure was initiated greater than 8 hours after arrival at this hospital.
    N (No) There is no documentation that the first endovascular treatment procedure was initiated greater than 8 hours after arrival at this hospital, OR unable to determine from medical record documentation.

    Notes for Abstraction:

    • If EVT was initiated greater than 8 hours after hospital arrival AND there was no EVT procedure, i.e., mechanical embolectomy/ thrombectomy and/or IA thrombolysis (alteplase) performed during the first 8 hours after hospital arrival, then select "Yes".
      Example:
      Patient arrives at the hospital ED on 01-11-20XX at 0013. NIHSS 2. IV alteplase given. On 01-14-20XX, patient found with slurred speech, left-sided facial droop and paresthesia. Stroke alert call at 0900. Thrombectomy performed on 01-14-20XX at 1010.
    • If EVT was initiated within 8 hours after hospital arrival and another EVT procedure performed later than 8 hours following hospital arrival, select "No".
      Example: Patient arrives at the hospital ED on 01-15-20XX at 1513. IA alteplase initiated at 1605. Thrombectomy performed 01-17-20XX at 0640.
    • If unable to determine, select "No".

    Suggested Data Sources:

    • Consultation notes
    • Diagnostic test reports
    • Operative notes
    • Operative report
    • Procedure notes
    • Procedure report

    Guidelines for Abstraction

    Inclusion:Patients with ICD-10-PCS procedure codes on Table 8.1a Thrombolytic Agent Procedures or Table 8.1b Mechanical Endovascular Reperfusion Procedures, if medical record documentation states that such a procedure was initiated later than 8 hours after hospital arrival

    Exclusion:Patients with ICD-10-PCS procedure codes on Table 8.1a Thrombolytic Agent Procedures or Table 8.1b Mechanical Endovascular Reperfusion Procedures, if medical record documentation states that such a procedure was initiated within 8 hours after hospital arrival


    Table Number 8.1a: Thrombolytic Agent Procedures (Version 2020A2)

    Table 8.1b Mechanical Endovascular Reperfusion Procedures (Version 2020A2)

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: Is there documentation of skin puncture at this hospital to access the arterial site selected for endovascular treatment of a cerebral artery occlusion?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Skin Puncture

    Collected For: CSTK-09, CSTK-12

    Definition: Puncture of the skin with a needle or introducer to provide an entry site for arterial access. Arterial access (e.g., brachial, carotid, femoral, radial) is needed for endovascular treatment of a cerebral artery occlusion with a device (e.g., stent-retriever) and/or intraarterial thrombolysis (alteplase).

    Suggested Data Collection Question:Is there documentation of skin puncture at this hospital to access the arterial site selected
    for endovascular treatment of a cerebral artery occlusion?

    Format:

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    Y (Yes) There is documentation of skin puncture at this hospital to access the arterial site selected for endovascular treatment of a cerebral artery occlusion.
    N (No) There is no documentation of skin puncture at this hospital to access the arterial site selected for endovascular treatment of a cerebral artery occlusion, OR unable to determine from medical record documentation.

    Notes for Abstraction:

    • If skin puncture was done at this hospital and documented in the medical record, select
      "Yes".
    • If skin puncture was not done at this hospital, select "No".
    • If skin puncture at this hospital is not documented or unable to determine from medical
      record documentation, select "No".

    Suggested Data Sources:

    • Consultation notes
    • Diagnostic test reports
    • Operative notes
    • Operative report
    • Procedure notes

    Guidelines for Abstraction

    Inclusion: Arterial access

    Exclusion: None

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE ^What is the date and time associated with the time of skin puncture at this hospital to access arterial site selected for endovascular treatment of a cerebral arteryocclusion?

    Data Element Name: Skin Puncture Date, Skin Puncture Time

    Collected For: CSTK-09,, CSTK-12

    Definition: The date associated with the time of skin puncture at this hospital to access the arterial site selected for endovascular treatment of a cerebral artery occlusion.

    Data Collection Question: What is the date associated with the time of skin puncture at this hospital to access the arterial site selected for endovascular treatment of a cerebral artery occlusion?

    Length: 10 - MM-DD-YYYY (includes dashes) or UTD

    Type: Date

    Occurs: 1

    MM = Month (01-12)

    DD = Day (01-31)

    YYYY = Year (2012-Current Year)

    UTD = Unable to Determine

    Notes for Abstraction:

    • If the date of skin puncture at this hospital is unable to be determined from medical record documentation, select "UTD."

    • The medical record must be abstracted as documented (taken at “face value”). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD.

    • Examples:

    • Documentation indicates that the Skin Puncture Date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the Skin Puncture Date is outside of the range listed in the Allowable Values for "Day," it is not a valid date and the abstractor should select "UTD."

    • Patient expires on 02-12-20xx and documentation indicates the Skin Puncture Date was 03-12-20xx. Other documentation in the medical record supports the date of death as being accurate. Since the Skin Puncture Date is after the Discharge Date (death), it is outside of the parameters of care and the abstractor should select "UTD."

    Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commission’s Data Warehouse. Use of "UTD" for Skin Puncture Date allows the case to be accepted into the warehouse.

    Suggested Data Sources:

    • Consultation notes
    • Diagnostic test reports
    • Operative notes
    • Operative report
    • Procedure notes
    • Procedure report

    Additional Notes:

    Guidelines for Abstraction: No exclusion criteria.

    REQUIRED FOR COMPREHENSIVE: Did the patient receive intravenous (IV) alteplase at this hospital or a transferring hospital prior to receiving intra-arterial (IA) alteplase or mechanical reperfusion therapy at this hospital?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: IV Thrombolytic Therapy Prior to IA or Mechanical Reperfusion Therapy

    Collected For: CSTK-05, CSTK-08, CSTK-10

    Definition: There is documentation in the record that the patient received intravenous (IV) thrombolytic (alteplase) therapy at this hospital or a transferring hospital prior to receiving intra-arterial (IA) thrombolytic therapy or mechanical reperfusion therapy at this hospital.

    Suggested Data Collection Question: Did the patient receive intravenous (IV) alteplase at this hospital or a transferring hospital prior to receiving intra-arterial (IA) alteplase or mechanical reperfusion therapy at this hospital?

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    Y (Yes) Patient received IV alteplase prior to IA thrombolytic therapy or mechanical reperfusion therapy.

    N (No) Patient did not receive IV alteplase prior to IA thrombolytic therapy or mechanical reperfusion therapy, OR unable to determine from medical record documentation.

    Notes for Abstraction:

    • Documentation in the medical record must reflect that the patient received IV thrombolytic (alteplase) therapy at this hospital or a transferring hospital (i.e., drip and ship) prior to receiving IA thrombolytic therapy or mechanical reperfusion therapy at this hospital.

    Suggested Data Sources:

    • Emergency department record
    • Progress notes
    • Medication records
    • Transfer forms
    • Medical transport records

    Guidelines for Abstraction

    Inclusion:

    Only Acceptable Thrombolytic Therapy for Stroke

    • Activase
    • Alteplase
    • IV alteplase
    • Recombinant Tissue Plasminogen Activator (rt-PA)
    • Tissue plasminogen activator (t-PA)

    Exclusion: None

    Summary of Changes

    Was a mechanical endovascular reperfusion procedure attempted during this episode of care (at this hospital)?

    Required Field, Guidance for GWTG- Stroke users

    Data Element Name: EVT attempted at this hospital

    Collected For: GWTG® EVT Measure Set

    Definition: Mechanical endovascular reperfusion procedures include the use mechanical clot disruption or retrieval and intracranial angioplasty. Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria (Class I; Level of Evidence A):


    • Pre-stroke mRS score 0 to 1,
    • Acute ischemic stroke receiving intravenous r-tPA within 4.5 hours of onset according the guidelines from professional medical societies,
    • Causative occlusion of the ICA or proximal MCA (M1),
    • Age ≥18 years,
    • NIHSS score of ≥6,
    • ASPECTS of ≥6,
    • Treatment can be initiated (groin puncture) within 6 hours of symptom onset

    Data Collection Question: Was a mechanical endovascular reperfusion procedure attempted during this episode of care (at this hospital)?

    Format:

    Length: 1

    Type: Alphanumeric

    Occurs: 1

    Y (Yes) Patient taken to the procedure suite with the intent of performing endovascular thrombectomy and at minimum arterial puncture was performed.

    N (No) Patient was taken to the procedure suite, but did not proceed with endovascular thrombectomy (e.g. improvement in patient condition or clot dissolved, thus procedure aborted).

    Notes for Abstraction:

    Select "No" if the patient was taken to the procedure suite and at minimum no arterial puncture was made.

    Examples of a mechanical endovascular devices include, but not limited to:

    • Solitaire
    • Trevo
    • Merci Retrieval System
    • Penumbra Stroke System
    • A Direct Aspiration First Pass Technique (ADAPT)

    Suggested Data Sources:

    • Consultation notes
    • Diagnostic test reports
    • Operative notes
    • Procedure notes
    • Medication records

    Additional Notes:

    None

    Guidelines for Abstraction:

    Exclusion: If medical record documentation does not indicate that the procedure attempted was a mechanical thrombectomy for removal of LVO.

    ^Was a mechanical thrombectomy procedure attempted but unsuccessful or aborted before removal of the LVO?

    Collected For: CSTK

    Definition: Documentation demonstrates that a mechanical thrombectomy procedure was attempted to remove a large vessel cerebral occlusion (LVO) but was unsuccessful and/or aborted.

    Question: Was a mechanical thrombectomy procedure attempted but unsuccessful or aborted before removal of the LVO?

    Format: Single Select

    Allowable Values:

    • Yes
    • No

    Notes for Abstraction:

    • Yes - There is documentation that a mechanical thrombectomy procedure was attempted but unsuccessful or aborted before removal of the LVO.
    • No - There is no documentation that a mechanical thrombectomy procedure was attempted but unsuccessful or aborted before removal of the LVO, OR unable to determine from medical record documentation.
    • If medical record documentation does not include an ICD-10-PCS Principal or Other Procedure Code on Table 8.1b Mechanical Endovascular Reperfusion Procedures, continue to review the record for documentation that an extirpation procedure failed. When documentation clearly indicates that a mechanical thrombectomy procedure was attempted but unsuccessful or aborted before removal of the LVO, select &qoot;Yes." Examples:
      • 67 Y/O male presents with acute right MCA stroke and occlusion. Neuroendovascular interventionalist documents in a procedure note, e.g., "Despite multiple passes with the wire, distal access with the microcatheter could not be obtained. Given the tortuosity, distal nature of clot, and chronicity/organization of the clot, the procedure was concluded."
      • Operative note states, e.g., "Attempted mechanical thrombectomy of M1 occlusion, S/P unsuccessful mechanical thrombectomy. Procedure terminated after multiple attempts at clot. The M1 segment remained occluded with no recanalization."
    • If a mechanical thrombectomy procedure was attempted and down coded to the root ICD-10-PCS Principal or Other Procedure Code due to extirpation procedure failure, select "Yes." A procedure code on Table 8.1c is not necessary to select "Yes" for this data element but may assist abstraction. Examples:
      • Operative note includes documentation that left groin was punctured but thrombectomy intervention could not be completed due to inability to access the target parent vessel. Pre-procedure TICI 0; post-procedure TICI 0. No root procedure code assigned. ICD-10-PCS B3121ZZ fluoroscopy is the only procedure code. Select "Yes".
      • ICD-10-PCS procedure code 037J3ZZ Dilation of Left Common Carotid Artery, Percutaneous Approach assigned. ICD-10-PCS 037J3ZZ is on Table 8.1c. Medical record documentation indicates that mechanical thrombectomy attempted but unsuccessful. Select "Yes".
    • If medical record documentation includes an ICD-10-PCS Principal or Other Procedure Code on Table 8.1b Mechanical Endovascular Reperfusion Procedures, select "No."
      • ICD-10-PCS procedure codes 037J3ZZ Dilation of Left Common Carotid Artery, Percutaneous Approach and 03CL3ZZ Extirpation of Matter from Left Internal Carotid Artery, Percutaneous Approach assigned. TICI score 2A post-procedure, select "No".
    • If medical record documentation includes only an ICD-10-PCS Principal or Other Procedure Code on Table 8.1c Thrombectomy Root Procedures and no documentation of extirpation procedure failure, select "No."
      • ICD-10-PCS procedure code 037J3ZZ Dilation of Left Common Carotid Artery, Percutaneous Approach assigned. Medical record documentation indicates that carotid artery stenting was performed. Select "No".
    • If medical record documentation mentions that a mechanical thrombectomy procedure was planned but not initiated, select "No".
      • Patient taken to the interventional suite for possible MER procedure. No arterial/groin puncture. Patient returned to ICU bed for monitoring, select "No".
      • Patient taken to angio for MER procedure. Groin punctured. Clot dissolved with IV t-PA. TICI 3. Mechanical thrombectomy not initiated, select "No".
    • If unable to be determined from medical record documentation that the procedure attempted was a mechanical thrombectomy for removal of a LVO, select "No"/UTD.

    Suggested Data Sources:

    • Consultation Notes
    • Diagnostic Test Reports
    • Operative Notes
    • Procedure Notes

    Additional Notes / Guidelines for Abstraction:

    • Inclusion:
      • Patients with ICD-10-PCS procedure codes on Table 8.1c Thrombectomy Root Procedures, if medical record documentation states that the mechanical thrombectomy procedure was attempted but unsuccessful or aborted before removal of the LVO. Refer to Appendix A, Table 8.1c Thrombectomy Root Procedures for examples of acceptable ICD-10-PCS procedure codes.
      • Patients with ICD-10-PCS procedure codes on Table 8.1c Thrombectomy Root Procedures, if medical record documentation does not indicate that the procedure attempted was a mechanical thrombectomy for removal of a LVO. Refer to Appendix A, Table 8.1c Thrombectomy Root Procedures for examples of acceptable ICD-10-PCS procedure codes.

    ^^Are reasons for not performing mechanical endovascular reperfusion therapy documented?
    Required field when enabled

    Data Element Name:

    Documented Reason for Not Performing MER

    Collected For:

    GWTG® EVT Measure Set

    Definition:

    Documented reason acute ischemic stroke patients for whom mechanical endovascular reperfusion therapy was not initiated during this episode of care at your hospital.

    Data Collection Question:

    Are reasons for not performing mechanical endovascular reperfusion therapy documented?

    Format:

    Length:

    1

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:

    Y (Yes) There is a documented reason by a physician/ANP/PA for not initiating mechanical endovascular reperfusion therapy during this episode of care.

    N (No) No documented reason in the medical record by a physician/ANP/PA for why mechanical endovascular reperfusion therapy was not initiated during this episode of care.

    Notes for Abstraction:

    Documentation in the medical record must be by a physician/ANP/PA.

    Suggested Data Sources:

    · Consultation notes

    · Procedure notes

    · Operative notes

    · Radiology Reports

    Additional Notes:

    None

    Guidelines for Abstraction: None.


    ^^Reasons for not performing mechanical endovascular reperfusion therapy (select all that apply):

    Required field when enabled

    Data Element Name:

    Reasons for Not Performing MER

    Collected For:

    GWTG® EVT Measure Set

    Definition:

    Acute ischemic stroke patients for whom mechanical endovascular reperfusion therapy was not initiated during this episode of care. Select the specific reason(s) documented in the medical record for not initiating mechanical endovascular reperfusion therapy at this hospital.

    Data Collection Question:

    Reasons for not performing mechanical endovascular reperfusion therapy (select all that apply):

    Format:

    Length:

    1

    Type:

    Multi-select field

    Occurs:

    Minimum: 1 option selected. Maximum: All 14 options selected

    Allowable Values:

    · Significant pre-stroke disability (pre-stroke mRS > 1)

    · No evidence of proximal occlusion

    · NIHSS < 6

    · Brain imaging not favorable (ASPECTS score < 6) /hemorrhage transformations

    · Groin puncture could not be initiated within 6 hours of symptom onset

    · Anatomical reason- unfavorable vascular anatomy that limits access to the occluded artery

    · Patient/family refusal

    · MER performed at outside hospital

    · Allergy to contrast material

    · Equipment-related delay *

    · No endovascular specialist available *

    · Delay in stroke diagnosis *

    · Vascular imaging not performed*

    · Advanced Age *

    · Other *

    * These reason does not exclude from measure population

    Notes for Abstraction:

    • The reasons are not intended to supersede physician judgement, but serve as a guideline to abstractors for acceptable reasons why MER was not initiated. As always, the physician must exercise due caution in providing treatment, given the risks and benefits to the individual patient and the available information at the time of treatment decision.

    • Documentation in the medical record must be by a physician/ANP/PA.

    • Inferences for the following three reasons can be made for not initialing endovascular therapy:

    1. No evidence of proximal occlusion

    2. NIHSS <6

    3. Brain imaging not favorable/hemorrhage transformation (ASPECTS score < 6)

    • All other reasons require documentation by a physician/APN/PA.

    Suggested Data Sources:

    · Consultation notes

    · Procedure notes

    · Operative notes

    · Radiology Reports

    Additional Notes:

    The response options with an asterisk (*), do not exclude the patient from the MER measure set.

    Guidelines for Abstraction: None.

    ^^If MER Treatment at this hospital, type of device:
    Required field when enabled 

    Data Element Name:

    Device used for EVT

    Collected For:

    GWTG® EVT Measure Set

    Definition:

    If MER Treatment at this hospital, select the type of treatment:

    Data Collection Question:

    What EVT provided at your hospital, what was the device used to provide this treatment?

    Format:

    Length:

    1

    Type:

    Multi-select

    Occurs:

    Minimum: 1 option selected. Maximum: All 6 options selected

    Allowable Values:

    · Retrievable stent

    · Another mechanical clot retriever device (not retrievable stent)

    · Clot suction device

    · Intracranial angioplasty, with or without permanent non-retrieved stent

    · Cervical carotid angioplasty, with or without stent

    · Other

    Notes for Abstraction:

    • Examples of a Retrievable stent: Solitaire and Trevo

    • Example of Other Mechanical Clot Retriever: Merci Retrieval System

    • Example of a Clot Suction Device: Penumbra Stroke System

    Suggested Data Sources:

    · Consultation notes

    · Procedure notes

    · Operative notes

    · Radiology Reports

    Additional Notes:

    None

    Guidelines for Abstraction: None.

    REQUIRED FOR COMPREHENSIVE: ^Is there documentation in the medical record of the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital?

    Data Element Name:

    First Pass of a Mechanical Reperfusion Device

    Collected For:

    CSTK-07, GWTG® - EVT Measures

    Definition:

    First pass (i.e., deployment) of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital. A mechanical reperfusion device is also known as a clot retrieval device. Clot retrieval devices are designed to treat ischemic stroke by removal of the clot from the cerebral artery. Several brand names are used to identify clot retrieval devices which include, Merci, Penumbra, Trevo, and Solataire. For purposes of this data element, “pass” means mechanical deployment of a clot retrieval device.

    Data Collection Question:

    Is there documentation in the medical record of the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital?

    Format:

    Length:

    1

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:

    Y (Yes) There is documentation of the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital.

    N (No) There is no documentation of the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital, OR unable to determine from medical record documentation.

    Notes for Abstraction:

    · If the first pass of the mechanical reperfusion device at this hospital is unable to be determined from medical record documentation, select “No”.

    · If conflicts with other sources documenting the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery, use the documentation found in the diagnostic test report.

    Suggested Data Sources:

    · Consultation notes

    · Diagnostic test reports

    · Operative notes

    · Procedure reports

    Additional Notes:

    Guidelines for Abstraction:

    Inclusion

    Exclusion

    · Access

    · Advance

    · Aspiration

    · Attempt

    · Deployment

    · Pass

    · Run

    None

    REQUIRED FOR COMPREHENSIVE: ^What is the date and time of the first pass of a clot retrieval device at this hospital?
    Required for GWTG

    Data Element Name:

    First Pass Date and Time

    Collected For:

    CSTK-07, GWTG® - EVT Measures

    Definition:

    The date and time (military time) of the first pass (i.e., mechanical deployment) of a clot retrieval device at this hospital.

    Data Collection Question:

    What is the date and time of the first pass (i.e., mechanical deployment) of a clot retrieval device at this hospital?

    Format:

    Length:

    15-

    MM-DD-YYYY (includes dashes)

    HH-MM (with or without colon)

    or Unknown

    Type:

    Date and Time

    Occurs:

    1

    Allowable Values:

    Date
    MM = Month (01-12) 
    DD = Day (01-31) 
    YYYY = Year (2012-Current Year) 
    UTD = Unknown

    Time

    HH = Hour (00-23) 
    MM = Minutes (00-59) 
    UTD = Unknown

    Time must be recorded in military time format. Except for Midnight and Noon:

    · If the time is in the a.m., conversion is not required

    · If the time is in the p.m., add 12 to the clock time hour

    Examples:

    Midnight = 00:00
    Noon = 12:00 
    5:31 am = 05:31
    5:31 pm = 17:31 
    11:59 am = 11:59
    11:59 pm = 23:59

     

    Note:
    00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the First Radiographic Image Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.

    When converting Midnight or 24:00 to 00:00, do not forget to change the First Radiographic Image Date.
    Example:
    Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx

    Notes for Abstraction:

    • If the date of the first pass is unable to be determined from medical record documentation, select Unknown
    • The medical record must be abstracted as documented (taken at face value). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD 
      Examples:
      • Documentation indicates the first pass date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the first pass date is outside of the range listed in the Allowable Values for “Day,” it is not a valid date and the abstractor should select “UTD”.
        • Patient expires on 02-12-20xx and documentation indicates the First Pass Date was 03-12-20xx. Other documentation in the medical record supports the date of death as being accurate. Since the First Pass Date is after the Discharge Date (death), it is outside of the parameters of care and the abstractor should select “UTD.”
    • For times that include “"seconds”", remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00.
    • If the First Pass Time is unable to be determined from medical record documentation, select “UTD”.
    • The medical record must be abstracted as documented (taken at “face value”). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select “UTD”.
      Example:
      Documentation indicates the first pass time was 3300. No other documentation in the medical record provides a valid time. Since the first pass time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD”.
    • The earliest time should be used regardless of how many vessels were treated or which ones were successful vs. unsuccessful.

    Suggested Data Sources:

    · Consultation notes

    · Diagnostic test reports

    · Procedure notes * Operative notes

    · Procedure report

    Additional Notes:

    Guidelines for Abstraction:

    Inclusion

    Exclusion

    None

    · Anesthesia start time

    · Groin puncture time

    · Procedure start time

    ^^Is a cause(s) for delay in performing mechanical endovascular reperfusion therapy documented?

     

    Data Element Name:

    Documented Reason for Delaying EVT

    Collected For:

    GWTG® EVT Measure Set

    Definition:

    As with intravenous r-tPA, reduced time from symptom onset to reperfusion with endovascular therapies is highly associated with better clinical outcomes. Thus, when there is a delay, what is the documented reason.

    Data Collection Question:

    Are reasons for delay in performing mechanical endovascular reperfusion therapy documented?

    Format:

    Length:

    1

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:

    Y (Yes) There is a documented reason for delay in initiating mechanical endovascular reperfusion therapy when it’s greater than 120 minutes after hospital arrival.

    N (No) No documented reason in the medical record for why there was a delay in initiating mechanical endovascular reperfusion therapy during this episode of care.

    Notes for Abstraction:

    Documentation in the medical record must be by a physician/ANP/PA.

    Suggested Data Sources:

    · Consultation notes

    · Procedure notes

    · Operative notes

    · Radiology Reports

    Additional Notes:

    None

    Guidelines for Abstraction: None.

    ^^If EVT Treatment at this hospital, type of device:
    Required field when enabled

    Data Element Name:

    Device used for EVT

    Collected For:

    GWTG® EVT Measure Set

    Definition:

    If MER Treatment at this hospital, select the type of treatment:

    Data Collection Question:

    What EVT provided at your hospital, what was the device used to provide this treatment?

    Format:

    Length:

    1

    Type:

    Multi-select

    Occurs:

    Minimum: 1 option selected. Maximum: All 6 options selected

    Allowable Values:

    · Retrievable stent

    · Another mechanical clot retriever device (not retrievable stent)

    · Clot suction device

    · Intracranial angioplasty, with or without permanent non-retrieved stent

    · Cervical carotid angioplasty, with or without stent

    · Other

    Notes for Abstraction:

    • Examples of a Retrievable stent: Solitaire and Trevo

    • Example of Other Mechanical Clot Retriever: Merci Retrieval System

    • Example of a Clot Suction Device: Penumbra Stroke System

    Suggested Data Sources:

    · Consultation notes

    · Procedure notes

    · Operative notes

    · Radiology Reports

    Additional Notes:

    None

    Guidelines for Abstraction: None.

    ^Is there documentation in the medical record of the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital?

    Data Element Name:

    First Pass of a Mechanical Reperfusion Device

    Collected For:

    CSTK-07

    Definition:

    First pass (i.e., deployment) of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital. A mechanical reperfusion device is also known as a clot retrieval device. Clot retrieval devices are designed to treat ischemic stroke by removal of the clot from the cerebral artery. Several brand names are used to identify clot retrieval devices which include, Merci, Penumbra, Trevo, and Solataire. For purposes of this data element, “pass” means mechanical deployment of a clot retrieval device.

    Data Collection Question:

    Is there documentation in the medical record of the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital?

    Format:

    Length:

    1

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:

    Y (Yes) There is documentation of the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital.

    N (No) There is no documentation of the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital, OR unable to determine from medical record documentation.

    Notes for Abstraction:

    · If the first pass of the mechanical reperfusion device at this hospital is unable to be determined from medical record documentation, select “No”.

    · If conflicts with other sources documenting the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery, use the documentation found in the diagnostic test report.

    Suggested Data Sources:

    · Consultation notes

    · Diagnostic test reports

    · Operative notes

    · Procedure reports

    Additional Notes:

    Guidelines for Abstraction:

    Inclusion

    Exclusion

    · Access

    · Advance

    · Aspiration

    · Attempt

    · Deployment

    · Pass

    · Run

    None

    ^What is the date and time of the first pass of a clot retrieval device at this hospital?
    Required for GWTG

     

    Data Element Name:

    First Pass Date and Time

    Collected For:

    GWTG® - EVT Measures

    Definition:

    The date and time (military time) of the first pass (i.e., mechanical deployment) of a clot retrieval device at this hospital.

    Data Collection Question:

    What is the date and time of the first pass (i.e., mechanical deployment) of a clot retrieval device at this hospital?

    Format:

    Length:

    15-

    MM-DD-YYYY (includes dashes)

    HH-MM (with or without colon)

    or Unknown

    Type:

    Date and Time

    Occurs:

    1

    Allowable Values:

    Date
    MM = Month (01-12) 
    DD = Day (01-31) 
    YYYY = Year (2012-Current Year) 
    UTD = Unknown

    Time

    HH = Hour (00-23) 
    MM = Minutes (00-59) 
    UTD = Unknown

    Time must be recorded in military time format. Except for Midnight and Noon:

    · If the time is in the a.m., conversion is not required

    · If the time is in the p.m., add 12 to the clock time hour

    Examples:

    Midnight = 00:00
    Noon = 12:00 
    5:31 am = 05:31
    5:31 pm = 17:31 
    11:59 am = 11:59
    11:59 pm = 23:59

     

    Note:
    00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the First Radiographic Image Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.

    When converting Midnight or 24:00 to 00:00, do not forget to change the First Radiographic Image Date.
    Example:
    Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx

    Notes for Abstraction:

    • If the date of the first pass is unable to be determined from medical record documentation, select Unknown
    • The medical record must be abstracted as documented (taken at face value). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD 
      Examples:
      • Documentation indicates the first pass date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the first pass date is outside of the range listed in the Allowable Values for “Day,” it is not a valid date and the abstractor should select “UTD”.
        • Patient expires on 02-12-20xx and documentation indicates the First Pass Date was 03-12-20xx. Other documentation in the medical record supports the date of death as being accurate. Since the First Pass Date is after the Discharge Date (death), it is outside of the parameters of care and the abstractor should select “UTD.”
    • For times that include “"seconds”", remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00.
    • If the First Pass Time is unable to be determined from medical record documentation, select “UTD”.
    • The medical record must be abstracted as documented (taken at “face value”). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select “UTD”.
      Example:
      Documentation indicates the first pass time was 3300. No other documentation in the medical record provides a valid time. Since the first pass time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD”.
    • The earliest time should be used regardless of how many vessels were treated or which ones were successful vs. unsuccessful.

    Suggested Data Sources:

    · Consultation notes

    · Diagnostic test reports

    · Procedure notes * Operative notes

    · Procedure report

    Additional Notes:

    Guidelines for Abstraction:

    Inclusion

    Exclusion

    None

    · Anesthesia start time

    · Groin puncture time

    · Procedure start time

    ^^Is a cause(s) for delay in performing mechanical endovascular reperfusion therapy documented?

     

    Data Element Name:

    Documented Reason for Delaying EVT

    Collected For:

    GWTG® EVT Measure Set

    Definition:

    As with intravenous r-tPA, reduced time from symptom onset to reperfusion with endovascular therapies is highly associated with better clinical outcomes. Thus, when there is a delay, what is the documented reason.

    Data Collection Question:

    Are reasons for delay in performing mechanical endovascular reperfusion therapy documented?

    Format:

    Length:

    1

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:

    Y (Yes) There is a documented reason for delay in initiating mechanical endovascular reperfusion therapy when it’s greater than 120 minutes after hospital arrival.

    N (No) No documented reason in the medical record for why there was a delay in initiating mechanical endovascular reperfusion therapy during this episode of care.

    Notes for Abstraction:

    Documentation in the medical record must be by a physician/ANP/PA.

    Suggested Data Sources:

    · Consultation notes

    · Procedure notes

    · Operative notes

    · Radiology Reports

    Additional Notes:

    None

    Guidelines for Abstraction: None.

    Reasons for delay (select all that apply):

    Data Element Name:

    Reasons for delaying EVT

    Collected For:

    GWTG® EVT Measure Set

    Definition:

    As with intravenous alteplase, reduced time from symptom onset to reperfusion with endovascular therapies is highly associated with better clinical outcomes. Indicate the reason(s) documented in the medical record for delay.

    Data Collection Question:

    Are reasons for delay in performing mechanical endovascular reperfusion therapy documented?

    Format:

    Length:

    1

    Type:

    Multi-select field

    Occurs:

    1 – 9

    Allowable Values:

    · Social/religious

    · Initial refusal

    · Care-team unable to determine eligibility

    · Management of concomitant emergent/acute conditions such as cardiopulmonary arrest, respiratory failure (requiring intubation)

    · Investigational or experimental protocol for thrombolysis

    · Additional proximal vascular procedure required prior to first pass (stent)

    · Need for additional PPE for suspected/ confirmed infectious disease

    · Delay in stroke diagnosis *

    · In-hospital time delay *

    · Equipment-related delay *

    · Need for additional imaging*

    · Catheter lab not available*

    Other * ___________

    * does not exclude patient from the measure population

    Notes for Abstraction:

    Documentation in the medical record must be by a physician/ANP/PA.

    • Social/Religious means that the patient and/or family refused treatment due to their cultural or religious beliefs. As patients do have the right to change their treatment decisions, this choice should be selected if there is documentation that treatment with EVT was initially refused due to any social or religious reason. Example: Patient wishes to consult clergy prior to deciding whether he wishes to receive treatment. Clergy takes 30 minutes to arrive. After speaking with clergy, the patient decides to proceed with treatment. Treatment is provided once the patient consents (now 75 minutes after arrival).
    • Initial refusal should be selected if there is documentation that the patient and/or family initially refused treatment for any reason other than a social/religious reason.
    • For patients that cannot participate in shared decision making or provide consent, select "Initial Refusal" if there is documentation that there was a delay in treatment due to reasonable attempts to contact a proxy decision maker to obtain consent.
    • "Care-team unable to determine eligibility" means that the diagnosis of stroke was made but that eligibility for EVT could not be established or verified by the clinician.
    • Management of concomitant emergent/acute conditions such as cardiopulmonary arrest, respiratory failure (requiring intubation)
    • Investigational or experimental protocol for thrombolysis: Documentation indicates that administration of IV alteplase was delayed due to an investigational or experimental thrombolytic protocol. If investigational or experimental protocol was used, there should be a signed IRB consent in the medical record.
    • "Additional proximal vascular procedure required prior to first pass (stent)" if a revascularization procedure (e.g. angioplasty, stenting, other), is performed in an artery proximal to the site of occlusion that is causing the stroke, before the first deployment of the EVT device. The most common example is the need to first perform angioplasty, with or without stenting, in a stenotic cervical internal carotid artery, to allow the passage of the EVT device to reach a distal target intracranial occlusion.
      • Do NOT select this reason if the delay was related to difficulty advancing catheters due to torturous anatomy or other reasons not unrelated to performing a proximal revascularization procedure
    • Need for additional PPE for suspected/ confirmed infectious disease: Select this option when there is documentation in the patient medical record that treatment was delayed so that health care providers could obtain additional Personal Protection Equipment (PPE) because the patient had a confirmed or suspected infection.

    Suggested Data Sources:

    · Consultation notes

    · Diagnostic test reports

    · Operative notes

    · Operative report

    · Procedure notes

    · Procedure report

    Additional Notes:

    None

    Guidelines for Abstraction: None.

    ^What is the location of the clot in the cerebral circulation?

    Data Element Name:

    Proximal or Distal Occlusion

    Collected For:

    CSTK-08,

    Definition:

    Documentation in the medical record of the location of the clot in either the large arteries in the neck or base of the brain (proximal), or small arteries higher up in the brain (distal). Arterial occlusions arising more proximally are associated with poorer outcomes.

    Data Collection Question:

    What is the location of the clot in the cerebral circulation?

    Format:

    Length:

    1

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:

    1 Proximal cerebral occlusion

    2 Distal cerebral occlusions

    3 Neither proximal or distal, OR unable to determine (UTD) from the medical record documentation

    Notes for Abstraction:

    · If the occlusion is documented in an artery listed as an inclusion term for "proximal", select ‘1’.

    · If the occlusion is documented in an artery listed as an inclusion term for "distal", select ‘2’.

    · If multiple occlusions, select "proximal" or "distal" for the primary vessel occlusion.

    · If unable to determine, select ‘3’.

    Suggested Data Sources:

    · Consultation notes

    · Emergency department record

    · History and physical

    · Progress notes

    · Discharge summary

    · Diagnostic test reports

    · Operative notes

    · Procedure notes

    · Admitting notes

    · Procedure reports

    Additional Notes:

    Guidelines for Abstraction:

    Inclusion

    Exclusion

    PROXIMAL:

    · Internal Carotid Artery (ICA)

    · ICA terminus

    · Middle Cerebral Artery (MCA)

    · Middle Cerebral Artery (MCA) M1 segment

    · M1

    · T-occlusion (T-lesion)

    · Vertebral Artery

    · Basilar Artery

    DISTAL:

    · Anterior Cerebral Artery (ACA)

    · Anterior Cerebral Artery (ACA) A1 segment

    · A1

    · Anterior Cerebral Artery (ACA) A2 segment

    · A2

    · Anterior Cerebral Artery (ACA) A3 segment

    · A3

    · Middle Cerebral Artery (MCA) M2 segment

    · M2

    · Middle Cerebral Artery (MCA) M3 segment

    · M3

    · Middle Cerebral Artery (MCA) M4 segment

    · M4

    · Posterior Cerebral Artery (PCA)

    · Posterior Cerebral Artery (PCA) P1 segment

    · P1

    · Posterior Cerebral Artery (PCA) P2 segment

    · P2

    · Posterior Cerebral Artery (PCA) P3 segment

    · P3

    None

    ^What cerebral artery is occluded?

     

    Note:

     

    Data Element Name:

     

    Similar GWTG® element appears under the Hospitalization Tab

    Site of Primary Vessel Occlusion

    Collected For:

    CSTK

    Definition:

    Documentation in the medical record of the clinical location of the primary occluded vessel.

    Data Collection Question:

    What cerebral artery is occluded?

    Format:

    Single-select

    Allowable Values:

    · Anterior cerebral artery (ACA)

    · A1 ACA

    · Anterior communicating artery

    · Internal carotid artery (ICA)

    · ICA terminus (T-lesion; T occlusion)

    · Middle cerebral artery (MCA)

    · M1 MCA

    · M2 MCA

    · M3/M4 MCA

    · Vertebral artery (VA)

    · Basilar artery (BA)

    · Posterior cerebral artery (PCA) 

    · Another cerebral artery branch/segment

    · The clinical location of the primary occluded vessel was not documented, OR unable to determine (UTD) from the medical record documentation.

    Notes for Abstraction:

  • Collect the documented clinical location of the primary occluded arterial segment treated with IA alteplase therapy and/or mechanical endovascular reperfusion therapy.
  • Suggested Data Sources:

    · Consultation notes

    · Emergency department record

    · History and physical

    · Progress notes

    · Discharge summary

    · Diagnostic test reports

    · Operative notes

    · Procedure notes

    · Admitting notes

    · Procedure reports

    Additional Notes/Guidelines for Abstraction: N/A

     

    ^^Thrombolysis in Cerebral Infarction (TICI) Post-Treatment Reperfusion Grade

    Data Element Name:

    TICI Reperfusion Grade

    Collected For:

    EVT Measure Set

    Definition:

    The Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade is used to measure cerebral reperfusion. Results with this scoring system range between zero and three: 0 (no perfusion); 1 (perfusion past the initial occlusion, but no distal branch filling); 2 (perfusion with incomplete or slow distal branch filling); and, 3 (full perfusion with filling of all distal branches). Reperfusion past the target arterial occlusion and into the distal arterial bed and terminal branches, in conjunction with recanalization of the target arterial occlusion, demonstrates flow restoration or revascularization.

    Question:

    Thrombolysis in Cerebral Infarction (TICI) Post-Treatment Reperfusion Grade

    Format:

    Single-select

    Allowable Values:

  • Grade 0
  • Grade 1
  • Grade 2a
  • Grade 2b
  • Grade 3
  • ND
  • Notes for Abstraction:

  • Grade 0: No Perfusion. No antegrade flow beyond the point of occlusion.
  • Grade 1: Penetration with Minimal Perfusion. The contrast material passes beyond the area of obstruction but fails to opacify the entire cerebral bed distal to the obstruction for the duration of the angiographic run.
  • Grade 2a: Partial tissue reperfusion in < 50% of the occluded artery.
  • Grade 2b: Partial reperfusion in ≥50% of the occluded artery territory.
  • Grade 3: Essentially complete Perfusion. Antegrade flow into the bed distal to the obstruction occurs as promptly as into the obstruction and clearance of contrast material from the involved bed is as rapid as from an uninvolved other bed of the same vessel or the opposite cerebral artery.
  • Select "Grade 2b" if documentation includes 2b, 2c, or a grade 2 with any modifier that indicates 50 - 99 percent reperfusion.
  • If a TICI reperfusion grade was not done post treatment or cannot be determined from medical record documentation, select “ND.”
  • TICI grade must be documented by a Physician/APN/PA.
  • Rationale: Endovascular therapy (EVT) is now the standard of care for treatment of acute ischemic stroke due to large-vessel occlusion (LVO). In 2015, the American Heart Association/American Stroke Association published a focused update to the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke regarding endovascular treatment (Powers WJ, et. al., 2015). Endovascular therapy with a stent retriever is recommended for eligible patients. To ensure benefit, reperfusion to TICI 2B/3 should be achieved as early as possible and within 6 hours of stroke onset. As with IV alteplase, reduced time from symptom onset to reperfusion with EVT is highly associated with better clinical outcomes.
  • Suggested Data Sources:

    · Consultation notes

    · Diagnostic test reports

    · Procedure reports

    Additional Notes / Guidelines for Abstraction:

     

  • Sang Hyun Suh, Harry J. Cloft, Jennifer E. Fugate, Alejandro A. Rabinstein, David S. Liebeskind and David F. Kallmes Stroke. 2013;44:1166-1168.
  • ^Is there a documented TICI reperfusion grade post-treatment?

    Data Element Name:

    Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade

    Collected For:

    CSTK-08, CSTK-11, CSTK-12,

    Definition:

    Documentation that the Thrombolysis in Cerebral Infarction (TICI) reperfusion grade was 2B (i.e., partial perfusion greater than or equal to 50% of vascular distribution of occluded artery) or higher post-treatment. The TICI scale is a tool used to grade the degree of perfusion obtained following recanalization of an arterial occlusion.

    Recanalization of an arterial occlusion increases reperfusion into distal segments of the artery and restores blood flow to brain tissue. Scores may range from 0 (no perfusion) to 3 (full perfusion with filling of all distal branches).

    Data Collection Question:

    Is there a documented TICI reperfusion grade post-treatment?

    Format:

    Length: 1

    Type: Alphanumeric

    Occurs: 1

    Allowable Values:

    1 = A TICI reperfusion grade greater than or equal to (≥) 2B was documented post-treatment.

    2 = A TICI reperfusion grade less than (<) 2B was documented post-treatment.

    3 = A TICI reperfusion grade was not done post-treatment, OR Unable to determine (UTD) from the medical record documentation.

    Notes for Abstraction:

    · The TICI grade may be documented by the physician/APN/PA, or a nurse (RN),circulating nurse, operating room technician, radiology technician or other individual designated to scribe during the procedure.

    · When multiple TICIs are documented because more than one vessel or branches of an artery are occluded, select the TICI grade associated with the site of primary vessel occlusion.

    ·When multiple TICIs are documented for the primary vessel occlusion, select the highest grade documented

    · If unable to determine whether the TICI reflects reperfusion of the primary vessel, then select "UTD".

    Suggested Data Sources:

    · Consultation notes

    · Emergency department record

    · History and physical

    · Progress notes

    · Discharge summary

    · Diagnostic test reports

    · Operative notes

    · Procedure notes

    · Admitting notes

    Guidelines for Abstraction:

     

    Inclusion:

    • Reperfusion time
    • Stroke reperfusion time

     Exclusion criteria:

    - TIBI, TIMI, or Scoring methodologies other than TICI

    Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Date/ Time

    Collected For: CSTK

    Definition: The date and time that a Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade was first documented during the mechanical thrombectomy procedure.

    Question: What was the date that a TICI was first documented during the mechanical thrombectomy procedure?

    Format: MM/DD/YYYY; HH:MM; Drop Down for Alternative Formats

    Allowable Values:

    • Date: MM/DD/YYYY
      • MM = Month (01-12)
      • MM = Month (01-12)
      • YYYY = Year (2012 - Current Year)
    • Time: 24 Hour Clock (Military Time)
      • HH = Hour (00-23)
      • MM = Minutes (00-59)
    • Unknown

    Notes for Abstraction:

    • Use the date a TICI 2B/3 was first documented. If a discrepancy exists in date documentation from different sources, choose the earliest date. If multiple dates are documented during the procedure, use the earliest date.
    • If a TICI 2B/3 was not achieved but a TICI less than 2B/3 was documented for the procedure, then select that date.
    • The procedure end date may be used if an earlier date is not documented during the procedure.
    • If the date a TICI 2B/3 was first documented is unable to be determined from medical record documentation, select "UTD".
    • The medical record must be abstracted as documented (taken at "face value"). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select "UTD". Example:
      • Documentation indicates the Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Date was 03-*42*-20xx. No other documentation in the medical record provides a valid date. Since the Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Date is outside of the range listed in the Allowable Values for "Day," it is not a valid date and the abstractor should select "UTD".
    • Time must be recorded in military time format. With the exception of Midnight and Noon:
      • If the time is in the a.m., conversion is not required
      • If the time is in the p.m., add 12 to the clock time hour
    • Use the time a TICI 2B/3 was first documented. If a discrepancy exists in time documentation from different sources, choose the earliest time. If multiple times are documented during the procedure, use the earliest time.
    • If a TICI 2B/3 was not achieved by a TICI less than 2B/3 was documented for the procedure, then select that time.
    • The procedure end time may be used if an earlier time is not documented during the procedure.
    • For times that include "seconds", remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00.
    • If the time a TICI 2B/3 was first documented is unable to be determined from medical record documentation, select "UTD".
    • A grade value (e.g., 2B/3) must be documented to meet this data element. Do not infer a TICI grade based on other documentation in the medical record, e.g., TICI estimated from the dictated angiography report.
    • The medical record must be abstracted as documented (taken at "face value"). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select "UTD". Example:
      • Documentation indicates the Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time was 3300. No other documentation in the medical record provides a valid time. Since the Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time is outside of the range listed in the Allowable Values for "Hour," it is not a valid time and the abstractor should select "UTD".

    Suggested Data Sources:

    • Consultation Notes
    • Progress Notes
    • Operative Notes
    • Procedure Notes

    Additional Notes / Guidelines for Abstraction:

    • Inclusion:
      • Recanalization Time
      • Reperfusion Time
      • Revascularization Time
      • Stroke Reperfusion Time
      • TICI Time

     


    Complications

    ^Was there a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrage following IV or IA alteplase therapy, or mechanical endovascular reperfusion therapy initiation?

    Collected For: CSTK

    Definition: Documentation of a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage following IV or IA alteplase therapy, OR mechanical endovascular reperfusion therapy initiation. The major risk of reperfusion therapy is hemorrhage

    Question: Was there a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrage following IV or IA alteplase therapy, or mechanical endovascular reperfusion therapy initiation?

    Format: Single Select

    Allowable Values:

    • Yes
    • No

    Notes for Abstraction:

    • Yes - Parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was detected on brain imaging following IV or IA alteplase therapy, or mechanical endovascular reperfusion therapy initiation.
    • No - Parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was not detected on brain imaging following IV or IA alteplase therapy, or mechanical endovascular reperfusion therapy initiation, OR Unable to determine (UTD) from the medical record documentation.
    • For purposes of this data element, do not use brain imaging reports for CT/MRI performed prior to IV or IA alteplase initiation, or mechanical endovascular reperfusion (MER) therapy. Abstract only brain imaging reports for tests done after these interventions to select ‘YES’.
    • Patients with a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage on brain imaging following IV or IA alteplase therapy, or mechanical endovascular reperfusion therapy initiation, are acceptable to select “Yes”.
      • A confirmed report is not necessary. Reports of preliminary findings within this timeframe may be used in abstraction.
      • If the report documents that “hemorrhage cannot be excluded”, “cannot R/O hemorrhage”, or “findings suggestive of hemorrhage”, select “Yes”.
    • When conflicting information is documented in the medical record, select ‘YES’.
    • Documentation that the hemorrhage is "old", select "NO". Do not infer that a hemorrhage is old unless explicitly documented.
    • See the inclusion list for acceptable examples of documentation of a positive finding. The list is not all inclusive.

    Suggested Data Sources:

    • ONLY acceptable data source:
      • Brain Imaging Reports
      • Diagnostic Test Reports
      • Radiology Reports

    Additional Notes / Guidelines for Abstraction:

    • Inclusion
      • Bleed
      • Blood
      • Blood product(s)
      • Brain hemorrhage
      • Cerebral hemorrhage
      • ECASS criteria PH1 or PH2
      • Hemorrhage
      • Hemorrhagic Conversion
      • Hemorrhagic Expansion
      • Hemorrhagic Transformation
      • Intracerebral Hemorrhage (ICH)
      • Intraparenchymal hemorrhage
      • Intraventricular hemorrhage
      • Parenchymal hematoma
      • Parenchymal hemorrhage
      • Parenchymal intracerebral hemorrhage
      • Small (e.g., bleed, hemorrhage)
      • Subarachnoid hemorrhage (SAH)
    • Exclusion
      • ECASS criteria H1 or H2
      • Incidental
      • Micro
      • Petechial
      • Punctate
      • Trace

    ^Date/Time of positive brain image:

    Data Element Name:

    Positive Brain Image Date and Time

    Collected For:

    CSTK-05,

    Definition:

    The month, date, and year for which a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was documented.

    The time (military time) for which a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was documented.

    Early hemorrhagic transformation occurs in about one in ten patients with acute ischemic stroke, but only parenchymal hematoma predicts poor outcomes, according to the research.

    Data Collection Question:

    What was the date and time of the positive brain image finding?

    Format:

    Length:

    10 - MM-DD-YYYY (includes dashes) or Unknown

    Type:

    Date

    Occurs:

    1

     

     

    Length:

    5 - HH-MM (with or without colon) or UTD

    Type:

    Time

    Occurs:

    1

    Allowable Values:


    MM = Month (01-12) 
    DD = Day (01-31) 
    YYYY = Year (2001-Current Year) 
    UTD = Unknown

    HH = Hour (00-23) 
    MM = Minutes (00-59) 
    UTD = Unable to Determine

     

    Notes for Abstraction:

    ·         Use the date when a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was first documented following IV or IA thrombolytic (alteplase) therapy, or mechanical endovascular reperfusion therapy initiation. If a discrepancy exists in date documentation from different sources, choose the earliest date. If there are two or more different positive brain image dates (either different brain images or corresponding with the same brain image), enter the earliest date.

    ·         If the date of positive brain image is unable to be determined from medical record documentation, select Unknown.


    Example:
    Documentation indicates the positive brain image date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the positive brain image date is outside of the range listed in the Allowable Values for Day, it is not a valid date and the abstractor should select Unknown. Time must be recorded in military time format. Except for Midnight and Noon:

    ·         If the time is in the a.m., conversion is not required

    ·         If the time is in the p.m., add 12 to the clock time hour

    ·         Examples:

    Midnight = 00:00
    Noon = 12:00 
    5:31 am = 05:31
    5:31 pm = 17:31 
    11:59 am = 11:59
    11:59 pm = 23:59

    Suggested Data Sources:

    ·         Diagnostic test reports

    ·         Brain imaging reports

    ·         Radiology reports

    Additional Notes:

     

    Guidelines for Abstraction:

     

    ·         Use the time at which symptomatic intracranial hemorrhage was first documented following IV or IA thrombolytic (alteplase) therapy, or mechanical endovascular reperfusion therapy initiation. If a discrepancy exists in time documentation from different sources, choose the earliest time. If there are two or more different symptomatic intracranial hemorrhage times (either different brain images or corresponding with the same brain image), enter the earliest time.

    ·         For times that include “seconds”, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00

    ·         If the time of symptomatic intracranial hemorrhage is unable to be determined from medical record documentation, select Unknown.

    ·         The medical record must be abstracted as documented (taken at face value). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select Unknown.

    ·         Example:
    Documentation indicates primary brain image time was 3300. No other documentation in the medical record provides a valid time. Since primary brain image time is outside of the range listed in the Allowable Values for hour. it is not a valid time and the abstractor should select Unknown.

     

    ^^Results of positive brain image
    Optional Field, Unique to GWTG

    Data Element Name:

    Results Positive Brain Image

    Collected For:

    GWTG ® Data Element

    Definition:

    Documentation of a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage following IV or IA thrombolytic (alteplase) therapy, OR mechanical endovascular reperfusion therapy initiation. The major risk of reperfusion therapy is hemorrhage

    Data Collection Question:

    Results of positive brain image

    Format:

    Length:  1

    Type:      Single-select, dropdown menu

    Occurs: 1

    Allowable Values:

    ·         PH2: Parenchymal Hematoma Type 2, defined by ECASS criteria as a hematoma occupying >30% of the infracted area accompanied by significant mass effect.

    ·         IVH: Intraventricular Hemorrhage

    ·         SAH: Subarachnoid Hemorrhage

    ·         RIH: Remote site of intraparenchymal hemorrhage outside the area of infarction

    ·         Other positive finding not listed above

    ·         None of the above or not documented

    Notes for Abstraction:

    ·          None.

    Suggested Data Sources:

    ·         Diagnostic test reports

    ·         Brain imaging reports

    ·         Radiology reports

    Guidelines for Abstraction:

     

    No additional Inclusion or exclusion criteria

     

     

    ^What is the last NIHSS score documented prior to initiation of IV thrombolytic therapy at this hospital?

     

    Data Element Name:

    NIHSS Score Documented Closest to IV Thrombolytic Initiation

    Collected For:

    CSTK-05

    Definition:

    The NIHSS score documented closest to IV thrombolytic initiation is the last NIHSS score documented prior to IV thrombolytic initiation at this hospital. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language.

    Data Collection Question:

    What is the last NIHSS score documented prior to initiation of IV thrombolytic therapy at this hospital?

    Format:

     

    Length:

    3

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:


    Score = 0-42 
    UTD = Unable to Determine

    Notes for Abstraction:

    ·         The NIHSS score may be documented by the physician/APN/PA or nurse (RN).

    ·         Look for the last NIHSS score documented prior to IV thrombolytic initiation at this hospital.
    Examples:

    o    “Initial NIHSS score 4 documented by the ED nurse at this hospital. “No other NIHSS scores were documented prior to IV alteplase initiation.” Select ‘4’.

    o    “Symptoms resolved by time of hospital arrival at 1200. Initial NIHSS score zero documented in ED. Symptoms returned at 1330, NIHSS score 2, and IV alteplase given at 1338.” Select ‘2’.

    o    “Patient transferred to this hospital. NIHSS score 10 done at transferring hospital. No NIHSS score documented at this hospital prior to IV alteplase.” Select ‘10’.

    o    “Nurse documented NIHSS score 8 via telemedicine prior to arrival at this hospital. IV alteplase initiated at 1712. NIHSS score 2 at 1800.” Select ‘8’.

    ·         For purposes of this data element, score documentation between 0 and 42 is acceptable. Only one score may be selected. Select the last NIHSS score documented prior to IV Thrombolytic Initiation Time at this hospital

    ·         If only one NIHSS score is documented prior to IV thrombolytic initiation and no other score(s) are available for comparison, enter the value for that score.

    ·         If no NIHSS score is documented prior to IV thrombolytic initiation, select UTD.

    ·         If unable to determine the last NIHSS score documented prior to IV thrombolytic initiation, select UTD.

    Suggested Data Sources:

    ·         Consultation notes

    ·         History and physical

    ·         Nursing flow sheet

    ·         Progress notes

    ·         Transfer sheet

    ·         Admitting note

    ·         Ambulance record

    ·         Emergency room records

    ·         Nursing assessment

    Additional Notes:

    None

    Guidelines for Abstraction:

    Inclusion

    Exclusion

    None

    ·         Modified NIHSS scores

    ·         Estimated NIHSS scores

    ·         Scoring methodologies other than NIHSS

     

    ^What is the highest NIHSS score documented within 36 hours following initiation of IV (alteplase) thrombolytic therapy?

     

    Data Element Name:

    Highest NIHSS Score Documented Within 36 Hours Following IV Thrombolytic Initiation

    Collected For:

    CSTK-05

    Definition:

    The highest NIHSS score documented within 36 hours following initiation of IV thrombolytic (alteplase) therapy. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language.

    Data Collection Question:

    What is the highest NIHSS score documented within 36 hours following initiation of IV (alteplase) thrombolytic therapy?

    >Format:

     

    Length:

    3

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:


    Score = 0-42 
    UTD = Unable to Determine

    Notes for Abstraction:

    ·         The NIHSS score may be documented by the physician/APN/PA or nurse (RN).

    ·         Look for the highest NIHSS score documented in less than or equal to 36 hours following initiation of IV thrombolytic (alteplase) therapy.

    ·         For purposes of this data element, score documentation between 0 and 42 is acceptable.

    ·         If only one NIHSS score is documented within the first 36 hours following initiation of IV thrombolytic (alteplase) therapy and no other NIHSS score(s) are available for comparison, enter the value for that score.

    ·         If multiple scores are documented within the first 36 hours following initiation of IV thrombolytic (alteplase) therapy, select the highest score.
    EXAMPLES:

    o    NIHSS Score is 10 at 1500 and 20 at 2300. Both scores are documented following the initiation of IV thrombolytic therapy. Select NIHSS score of 20.

    o    IV thrombolytic therapy initiated on 9/5/20XX at 0900. NIHSS score is 8 on 9/5/20XX at 2300, 10 on 9/6/20XX at 0100, and 8 on 9/6/20XX at 0300. Select NIHSS score 10.

    o    IV thrombolytic therapy initiated on 9/5/20XX at 0900. NIHSS score 3 on 9/6/20XX at 0900, 2 on 9/8/20XX at 0900, and 6 on 9/10/2012 at 0900. Select 3.

    ·         If no NIHSS score is documented within 36 hours following IV thrombolytic (alteplase) therapy, select “UTD”.

    ·         If unable to determine the highest score documented within 36 hours following IV thrombolytic (alteplase) therapy, select “UTD”.

    Suggested Data Sources:

    ·         Consultation notes

    ·         Emergency department record

    ·         History and physical

    ·         Nursing flow sheet

    ·         Progress notes

    ·         Admitting note

    ·         Nursing assessment

    Additional Notes:

     

    Guidelines for Abstraction:

    Inclusion

    Exclusion

    None

    ·         Modified NIHSS scores

    ·         Estimated NIHSS scores

    ·         Scoring methodologies other than NIHSS

     

    ^What is the last NIHSS score documented prior to initiation of IA alteplase or MER at this hospital?

     

    Data Element Name:

    NIHSS Score Documented Closest to IA alteplase or MER Initiation

    Collected For:

    CSTK-05,

    Definition:

    The NIHSS score documented closest to IA thrombolytic (alteplase) therapy or mechanical endovascular reperfusion (MER) therapy initiation is the last NIHSS score documented prior to IA alteplase or MER initiation (i.e., the initiation time of the intervention performed first) at this hospital. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language.

    Data Collection Question:

    What is the last NIHSS score documented prior to initiation of IA alteplase or MER at this hospital?

    Format:

     

    Length:

    3

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:


    Score = 0-42 
    UTD = Unable to Determine

    Notes for Abstraction:

    ·         The NIHSS score may be documented by the physician/APN/PA or nurse (RN).

    ·         Look for the last NIHSS score documented prior to IA alteplase or MER initiation at this hospital.
    Examples:

    o    “Initial NIHSS score 4 documented by the ED nurse at this hospital. No other NIHSS scores were documented prior to IA alteplase or MER initiation.” Select ‘4’.

    o    “NIHSS score 6 prior to transfer to this hospital. IV alteplase ‘drip and ship’. Arrival Time at this hospital 2319. NIHSS score 8 at 2325 and NIHSS score 10 at 2340. IA Thrombolytic Initiation Time 0015.” Select ‘10’.

    o    “NIHSS score 10 on arrival. IV alteplase given at 0800. NIHSS score 8 at 0900. IA infusion start time 0950.” Select ‘8’.

    o    “IV alteplase given at a transferring hospital. Nurse documented NIHSS score 18 via telemedicine prior to arrival at this hospital. Patient went directly to OR for mechanical thrombectomy procedure. No NIHSS score documented at this hospital prior to intervention.” Select ‘18’.

    ·         For purposes of this data element, score documentation between 0 and 42 is acceptable. Only one score may be selected. Select the last NIHSS score documented prior to the start time of IA alteplase OR first pass of a mechanical reperfusion device whichever intervention is performed first, i.e. “IA alteplase first then MER” or “MER first then IA alteplase”, at this hospital.

    ·         If only one NIHSS score is documented prior to IA alteplase or MER initiation and no other score(s) are available for comparison, enter the value for that score.

    ·         If no NIHSS score is documented prior to IA alteplase or MER initiation, select UTD.

    ·         If unable to determine the last NIHSS score documented prior to IA alteplase or MER initiation, select UTD.

    Suggested Data Sources:

    ·         Consultation notes

    ·         History and physical

    ·         Nursing flow sheet

    ·         Progress notes

    ·         Transfer sheet

    ·         Admitting note

    ·         Ambulance record

    ·         Emergency room records

    ·         Nursing assessment

    Additional Notes:

     

    Guidelines for Abstraction:

    Inclusion

    Exclusion

    None

    ·         Modified NIHSS scores

    ·         Estimated NIHSS scores

    ·         Scoring methodologies other than NIHSS

     

    ^What is the highest NIHSS score documented within 36 hours following IA alteplase or EVT initiation?

     

    Data Element Name:

    Highest NIHSS Score Documented Within 36 Hours Following IA alteplase or MER Initiation

    Collected For:

    CSTK-05

    Definition:

    The highest NIHSS score documented within 36 hours following initiation of IA thrombolytic (alteplase) therapy or mechanical endovascular reperfusion therapy (MER). The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language.

    Data Collection Question:

    What is the highest NIHSS score documented within 36 hours following IA alteplase or MER initiation?

    Format:

     

    Length:

    3

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:


    Score = 0-42 
    UTD = Unable to Determine

    Notes for Abstraction:

    ·         The NIHSS score may be documented by the physician/APN/PA or nurse (RN).

    ·         Look for the highest NIHSS score documented in less than or equal to 36 hours following initiation of IA alteplase or MER therapy.

    ·         For purposes of this data element, score documentation between 0 and 42 is acceptable.

    ·         If only one NIHSS score is documented within the first 36 hours following initiation of IA alteplase or MER therapy and no other NIHSS score(s) are available for comparison, enter the value for that score.

    ·         If multiple scores are documented within the first 36 hours following initiation of IA alteplase or MER therapy, select the highest score.
    EXAMPLES:

    o    IA alteplase initiated at 1247 with first deployment of a mechanical reperfusion device at 1303. NIHSS Score is 10 at 1500 and 20 at 2300. Select NIHSS score of 20.

    o    IA alteplase infusion initiated on 9/5/20XX at 0900. NIHSS score is 8 on 9/5/20XX at 2300, 10 on 9/6/20XX at 0100, and 8 on 9/6/20XX at 0300. Select NIHSS score 10.

    o    MER initiated on 9/5/20XX at 0900. NIHSS score 3 on 9/6/20XX at 0900, 2 on 9/8/20XX at 0900, and 6 on 9/10/2012 at 0900. Select 3.

    ·         If no NIHSS score is documented within 36 hours following IA alteplase or MER therapy initiation, select UTD.

    ·         If unable to determine the highest score documented within 36 hours following IA alteplase or MER therapy initiation, select UTD.

    Suggested Data Sources:

    ·         Consultation notes

    ·         Emergency department record

    ·         History and physical

    ·         Nursing flow sheet

    ·         Progress notes

    ·         Admitting note

    ·         Nursing assessment

    Additional Notes:

     

    Guidelines for Abstraction:

    Inclusion

    Exclusion

    None

    ·         Modified NIHSS scores

    ·         Estimated NIHSS scores

    ·         Scoring methodologies other than NIHSS

     

    ^Is there documentation that a procoagulant reversal agent was initiated at this hospital?

     

    Data Element Name:

    Procoagulant Reversal Agent Initiation

    Collected For:

    CSTK-04,

    Definition:

    A procoagulant reversal agent was initiated at this hospital. Procoagulant reversal agents are medications that increase coagulation factors to promote clotting.

    Data Collection Question:

    Is there documentation that a procoagulant reversal agent was initiated at this hospital?

    Format:

     

    Length:

    1

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:

    Y (Yes) A procoagulant reversal agent was initiated at this hospital.

    N (No) A procoagulant reversal agent was not initiated at this hospital, OR unable to determine from medical record documentation.

    Notes for Abstraction:

    ·         If a procoagulant reversal agent was initiated at this hospital, select Yes.

    ·         Only accept reversal agents identified in the list of inclusions. No other terms for reversal agents will be accepted.

    ·         If Vitamin K only was administered as the sole form of reversal and no other procoagulant agent was administered, select No.

    Suggested Data Sources:

    ·         Emergency department record

    ·         Nursing flow sheet

    ·         Progress notes

    ·         Medication administration record (MAR)

    ·         Medication reconciliation form

    Additional Notes:

     

    Guidelines for Abstraction:

    Inclusion

    Exclusion

    ·         Activated prothrombin complex concentrates

    ·         Anti-inhibitor coagulant complex

    ·         Autoplex T

    ·         Bebulin VH

    ·         Eptacog alfa

    ·         Factor IX Complex

    ·         Factor VIIa (Recombinant)

    ·         Feiba VH Immuno

    ·         Fresh frozen plasma (FFP)

    ·         NovoSeven

    ·         NovoSeven RT

    ·         Profiling SD

    ·         Proplex T

    ·         Prothrombin complex concentrates (PCCs

    ·         rFVIIa

    ·         (Kcentra) PCC-Human

    ·         Pradaxa (dabigatran) reversal agent: Praxbind (idarucizumab)

    ·         Vitamin K Only

    ·         Factor IX (without complex)

     

    ^^Date/Time procoagulant initiated
    Required field

     

    Data Element Name:

    Date/Time procoagulant initiated

    Collected For:

    GWTG ® Data Element, Optional field

    Definition:

     The Date/Time procoagulant therapy was initiated at this hospital.

    Data Collection Question:

    Date/Time procoagulant initiated

    Format:

    Length:

    10 - MM-DD-YYYY (includes dashes) or Unknown

    Type:

    Date

    Occurs:

    1

     

     

     

    Length:

    5 - HH-MM (with or without colon) or Unknown

    Type:

    Time

    Occurs:

    1

    Allowable Values:

    ·         Date and Time

    ·         Date only

    ·         Unknown

    Notes for Abstraction:

    ·          If patient receives multiple acceptable procoagulant therapies, enter the date that the first treatment was initiated.

    Suggested Data Sources:

    ·         Emergency department record

    ·         Nursing flow sheet

    ·         Progress notes

    ·         Medication administration record (MAR)

    ·         Medication reconciliation form

    Guidelines for Abstraction:

    No additional Inclusion or exclusion criteria

    ^Is there documentation by a physician/APN/PA or pharmacist in the medical record of a reason for not administering a procoagulant reversal agent?  

     

    Data Element Name:

    Reason for Not Administering a Procoagulant Reversal Agent

    Collected For:

    CSTK-04,

    Definition:

    Reason for not administering a procoagulant reversal agent.

    ·         Adverse reaction to a procoagulant reversal agent

    ·         Other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist.

    Procoagulant reversal agents are medications that increase coagulation factors to promote clotting.

    Data Collection Question:

    Is there documentation by a physician/APN/PA or pharmacist in the medical record of a reason for not administering a procoagulant reversal agent?

    Format:

     

    Length:

    1

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:

    Y (Yes) There is documentation of a reason for not administering a procoagulant reversal agent.

    N (No) There is no documentation of a reason for not administering a procoagulant reversal agent OR unable to determine from medical record documentation.

    Notes for Abstraction:

    ·         Reasons for not administering a procoagulant reversal agent must be documented by the physician/APN/PA or pharmacist.

    • Physician/APN/PA or pharmacist documentation of a hold on a procoagulant reversal agent or discontinuation of a procoagulant reversal agent constitutes a ?#8364;œclearly implied?#8364;? reason for not administering the procoagulant reversal agent.

    ·         If reasons are not mentioned in the context of a procoagulant reversal agent, do not make inferences (e.g., do not assume that a procoagulant reversal agent was not administered because of an adverse reaction to a procoagulant reversal agent unless documentation explicitly states so.)

    o    Reasons must be explicitly documented (e.g., “Allergic to cow milk. Do not give NovoSeven.

    ·         When conflicting information is documented in the medical record, select “Yes.”

    Suggested Data Sources:

    ·         Consultation notes

    ·         Emergency department record

    ·         History and physical

    ·         Progress notes

    ·         Discharge summary

    Additional Notes:

     

    Guidelines for Abstraction:

    Inclusion

    Exclusion

    ·         Patient/family refusal

    None

     

    ^^If initial INR > 1.4 and treated with procoagulant, Date/Time first INR ≤ 1.4 after treatment:
    Optional Field

     

    Data Element Name:

    Date/Time first INR ≤ 1.4 after treatment

    Collected For:

    GWTG ® Data Element, Optional field

    Definition:

    Documentation that the international normalized ratio (INR) value after treatment is less than 1.4. This value correlates to the ability of the blood to clot. Higher values greater than 1.4 are associated with an increased risk of hemorrhage.

     

    The first date/time recorded after treatment with procoagulant that the INR is less than or equal to 1.4.

    Data Collection Question:

    ^^If initial INR > 1.4 and treated with procoagulant, Date/Time first INR ≤ 1.4 after treatment:

    Format:

    Length:

    10 - MM-DD-YYYY (includes dashes) or Unknown

    Type:

    Date

    Occurs:

    1

     

     

     

    Length:

    5 - HH-MM (with or without colon) or Unknown

    Type:

    Time

    Occurs:

    1

    Allowable Values:

    ·         Date and Time (military time)

    ·         Date only

    ·         No documented INR ≤ 1.4 after Tx

    Notes for Abstraction:

    ·         If there is no documentation of an INR value less than 1.4 after treatment with procoagulant, select the checkbox that indicates ‘No documented INR ≤ 1.4 after Tx.’

    Suggested Data Sources:

    ·         Emergency department record

    ·         Nursing flow sheet

    ·         Progress notes

    ·         Medication administration record (MAR)

    ·         Medication reconciliation form

    Guidelines for Abstraction:

    No additional Inclusion or exclusion criteria

     


    HEMORRHAGIC STROKE TREATMENT

    ^Is there documentation that nimodipine was administered at this hospital?
    Required for TJC CSTK Users

     

    Data Element Name:

     

    Nimodipine Administration

    Collected For:

    CSTK-06

    Definition:

    Documentation that nimodipine was administered at this hospital. Nimodipine is a cerebroselective calcium channel blocker that inhibits calcium transport into vascular smooth muscle cells, thereby suppressing contractions. Nimodipine is used in the treatment of subarachnoid hemorrhage patients to prevent or limit the severity of cerebral vasospasm.

    Data Collection Question:

    Is there documentation that nimodipine was administered at this hospital?

    Format:

     

    Length:

    1

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:

    Y (Yes) Nimodipine was administered at this hospital.

    N (No) Nimodipine was not administered at this hospital, OR unable to determine from medical record documentation.

    Notes for Abstraction:

    ·         Nimodipine treatment must be administered at this hospital within the first 24 hours of arrival to select “'YES'. It is not necessary to review documentation outside of this timeframe.

    ·         If nimodipine was administered at another hospital and the patient was subsequently transferred to this hospital and nimodipine treatment continued admission to this hospital, select “'YES'”.

    ·         If nimodipine was administered at this hospital later than the first 24 hours after arrival, select 'NO'.

    ·         If nimodipine was administered at another hospital and the patient was subsequently transferred to this hospital and nimodipine treatment was not resumed or discontinued, select “'NO'.

    ·         A physician order for nimodipine that is not executed, select “'NO'”.

    Suggested Data Sources:

    ·         Emergency department record

    ·         Nursing flow sheet

    ·         Progress notes

    ·         Medication administration record (MAR)

    ·         Medical transport records

    ·         Medication reconciliation form

    Additional Notes:

     

    Guidelines for Abstraction:

    Inclusion

    Exclusion

    ·         Nimodipine

    ·         Nimotop

    ·         Nymalize

    All other calcium channel blocker medications other than those listed as inclusions.

     

    ^What is the date and time that nimodipine was first administered to this patient at this hospital?
    Required for TJC CSTK Users

     

    Data Element Name:

    Nimodipine Administration Date and Time

    Collected For:

    CSTK-06

    Definition:

    The date and time (military time) for which the first dose of nimodipine was administered to a patient with subarachnoid hemorrhage at this hospital. Nimodipine inhibits calcium transport into vascular smooth muscle cells, thereby preventing or limiting cerebral vasospasm.

    Data Collection Question:

    What is the date and time of nimodipine administration for this patient at this hospital?

    Format:

    Length:

    10 - MM-DD-YYYY (includes dashes) or Unknown

    Type:

    Date

    Occurs:

    1

     

    Length:

    5 - HH-MM (with or without colon) or Unknown

    Type:

    Time

    Occurs:

    1

    Allowable Values:

    ·         Date and Time (military time)

    ·         Date only

    ·         Unknown

    Notes for Abstraction:

    ·         Use the date at which administration of nimodipine was first documented. If a discrepancy exists in date documentation from different sources, choose the earliest date. If there are two or more different nimodipine administration dates (either different nimodipine episodes or corresponding with the same episode), enter the earliest date.

    ·         If the date nimodipine treatment was administered is unable to be determined from medical record documentation, select Unknown.

    ·         The medical record must be abstracted as documented (taken at face value). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select Unknown.
    Example:
    Documentation indicates the nimodipine administration date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the nimodipine administration date is outside of the range listed in the Allowable Values for Day, it is not a valid date and the abstractor should select UTD.

    ·         Use the time at which initiation of nimodipine administration was first documented. If a discrepancy exists in time documentation from different sources, choose the earliest time. If there are two or more different nimodipine administration times (either different nimodipine episodes or corresponding with the same episode), enter the earliest time.

    ·         For times that include seconds, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00

    ·         Nimodipine administration time refers to the time that the first dose of nimodipine was administered.

    ·         Do not use physician orders as they do not demonstrate administration of nimodipine treatment (in the ED this may be used if signed/initialed by a nurse).

    ·         If the time of nimodipine administration is unable to be determined from medical record documentation, select Unknown.

    ·         The medical record must be abstracted as documented (taken at face value). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select Unknown.

    ·         Example:
    Documentation indicates the nimodipine administration time was 3300. No other documentation in the medical record provides a valid time. Since the nimodipine administration time is outside of the range listed in the Allowable Values for Hour, it is not a valid time and the abstractor should select Unknown.

     

    ·         Note: Transmission of a case with an invalid date or time as described above will be rejected from the Joint Commission’s Data Warehouse. Use of Unknown for Nimodipine Administration Time allows the case to be accepted into the warehouse.

    Suggested Data Sources:

    ·         Emergency department record

    ·         Nursing flow sheet

    ·         Progress notes

    ·         Medication administration record (MAR)

    ·         Medical transport records

    ·         Medication reconciliation form

    Additional Notes:

    None.

    Guidelines for Abstraction:  None.

     

    ^Is there documentation by a physician/APN/PA or pharmacist in the medical record of a reason for not administering nimodipine treatment?
    Required for TJC CSTK Users

     

    Data Element Name:

    Reason for Not Administering Nimodipine Treatment

    Collected For:

    CSTK-06

    Definition:

    Reason for not administering nimodipine treatment:

    ·         Nimodipine allergy

    ·         Non-aneurysmal subarachnoid hemorrhage (SAH)

    ·         Reversible cerebral vasoconstriction syndrome

    ·         Cerebral amyloid angiopathy

    ·         Other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist.

    ·         In general, nimodipine inhibits calcium transport into vascular smooth muscle cells, thereby preventing or limiting cerebral vasospasm.

    Data Collection Question:

    Is there documentation by a physician/APN/PA or pharmacist in the medical record of a reason for not administering nimodipine treatment?

    Format:

     

    Length:

    1

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:

    Y (Yes) There is documentation of a reason for not administering nimodipine treatment.

    N (No) There is no documentation of a reason for not administering nimodipine treatment, OR unable to determine from medical record documentation.

    Notes for Abstraction:

    ·         Reasons for not administering nimodipine must be documented by the physician/APN/PA or pharmacist within 24 hours of hospital arrival. It is not necessary to review documentation outside of this timeframe.

    ·         The following are acceptable as stand-alone reasons for not administering nimodipine treatment – Nimodipine linkage is not needed:

    o    Non-aneurysmal subarachnoid hemorrhage (SAH)

    o    Reversible cerebral vasoconstriction syndrome

    o    Cerebral amyloid angiopathy

    ·         If reasons are not mentioned in the context of nimodipine treatment, do not make inferences (e.g., do not assume that nimodipine was not administered because of hypotension unless documentation explicitly states so.)

    o    Reasons must be explicitly documented (e.g., BP 80/40 No nimodipine.)

    o    Physician/APN/PA or pharmacist documentation of a hold on nimodipine or discontinuation of nimodipine that occurs within the first 24 hours of hospital arrival constitutes a “clearly implied” reason for not administering nimodipine treatment. A hold/discontinuation of all P.O. medications counts if nimodipine (i.e., Nimotop, Nymalize) was on order at the time of the notation. 
    EXCEPTION:
    Documentation of a conditional hold or discontinuation of nimodipine (e.g., Hold nimodipine if SBP < 100 mm/Hg, Stop nimodipine if AST > 50 IU/L.

    ·         When conflicting information is documented in the medical record, select Yes.

    ·         Documentation that the patient is NPO or has a nasogastric tube (NGT) without mention that nimodipine should not be administered is insufficient. Do not infer that nimodipine is not needed unless explicitly documented.

    o    Physician orders for NPO except medications” does not count as a reason for not administering nimodipine, select No.

    Suggested Data Sources:

    ·         Emergency department record

    ·         Nursing flow sheet

    ·         Progress notes

    ·         Medication administration record (MAR)

    ·         Medication reconciliation form

    Additional Notes:

    Excluded Data Sources:

    ·         Any documentation dated/timed later than 24 hours after hospital arrival.

    Guidelines for Abstraction:

    Inclusion

    Exclusion

     Patient/family refusal

    None

     

    ^^Surgical treatment for ICH at this hospital?

     

    Data Element Name:

    Surgical treatment for ICH at this hospital

    Collected For:

    GWTG ® Data Element, Optional field

    Definition:

    Indicate if surgical treatment was initiated at this hospital for ICH.

    Data Collection Question:

    Surgical treatment for ICH at this hospital?

    Format:

    Length:

    1

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:

    ·         Y (Yes) surgical treatment for ICH at this hospital.

    ·         N (No) surgical treatment for ICH at this hospital OR unable to determine from medical record documentation

    Notes for Abstraction:

    ·         None.

    Suggested Data Sources:

    ·         Emergency department record

    ·         Nursing flow sheet

    ·         Progress notes

    ·         Medication administration record (MAR)

    ·         Medication reconciliation form

    Guidelines for Abstraction:

    No additional Inclusion or exclusion criteria

     

    ^^If surgical treatment for ICH at this hospital, type:

    Data Element Name:

    Type of surgical treatment for ICH

    Collected For:

    GWTG ® Data Element, Optional field

    Rationale and Definition:

    Indicate type of surgical intervention performed at this hospital for ICH.

     

    Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular

    obstruction should undergo surgical removal of the hemorrhage as soon as possible (Class I; Level of Evidence B). Initial treatment of these patients with

    ventricular drainage rather than surgical evacuation

    is not recommended (Class III; Level of Evidence C). (Unchanged from the previous guideline)

     

    For most patients with supratentorial ICH, the usefulness of surgery is not well established (Class IIb; Level of Evidence A).

    Specific exceptions and potential subgroup considerations are outlined below in recommendations

    The effectiveness of minimally invasive clot evacuation with stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain (Class IIb; Level of Evidence B). (Revised from the previous guideline)

    Data Collection Question:

    ^^ If surgical treatment for ICH at this hospital, type

    Format:

    Length:

    1

    Type:

    Alphanumeric

    Occurs:

    1

    Allowable Values:

    ·         External Ventricular Drain (EVD)

    ·         Endoscopic evacuation

    ·         Conventional craniotomy and evacuation of clot under direct vision

    ·         Stereotaxic evacuation

    ·         Hemicraniectomy without clot evacuation

    ·         Fibrinolytic infusion via catheter

    ·         Other

    Notes for Abstraction:

    ·         None.

    Suggested Data Sources:

    ·         Progress notes

    ·         Medication reconciliation form Consultation notes

    ·         Emergency department record

    ·         Discharge summary

    Guidelines for Abstraction:

    No additional Inclusion or exclusion criteria

     

    ^^If ICH was evacuated, time from ictus to evacuation procedure start was:

    Data Element Name:

    Time from ictus to evacuation procedure start

    Collected For:

    GWTG ® Data Element, Optional field

    Definition:

    The total hours from the onset of stroke to the start of the surgical procedure.

    Data Collection Question:

    ^^If ICH was evacuated, time from ictus to evacuation procedure start was:

    Format:

    Length:

    2

    Type:

    Numeric

    Occurs:

    1

    Allowable Values:

    ·         Indicate the time, in hours, between ictus and surgery.

    Notes for Abstraction:

    ·         The start of surgery is defined as the time documented in the operative or procedure note.

    Suggested Data Sources:

    ·         Progress notes

    ·         Medication reconciliation form Consultation notes

    ·         Emergency department record

    ·         Discharge summary

    Guidelines for Abstraction:

    No additional Inclusion or exclusion criteria

    OPTIONAL: IA catheter-based treatment at outside hospital?

    Indicate if IA catheter-based treatmen was initiated at an outside hospital prior to transfer to this hospital.

    • Yes
    • No

    Admission Data, Hospitalization Data


    Measurements (first measurement upon presentation to your hospital)

    Lipids, A1C, and Blood Glucose

    Record patient's lipid, A1C, and blood glucose values.

    • Total Chol (mg/dL)
    • Triglycerides (mg/dL)
    • HDL (mg/dL)
    • REQUIRED: LDL (mg/dL)
    • Lipids ND: Only select if ALL of the lipid values are not documented or if the first lipid values available are measured greater than 48 hours after arrival.
    • Lipids NC: Only select if the patient refuses to have labs drawn or there is documentation that the patient is comfort measures only within 48 hours of arrival.
    • A1C (%)
    • A1C ND: A1C value is not measured or is measured but the value is not available.
    • REQUIRED FOR COMPREHENSIVE & PATIENTS THAT RECEIVE IV alteplase: What is the first blood glucose value obtained prior to or after hospital arrival?
    • Blood Glucose ND: Blood glucose is not measured or is measured but the value is not available.
    • Blood Glucose Too High or Too Low: If the glucometer reading states “Low” or “High” as opposed to a numeric value, select the appropriate checkbox of either “Too Low” or “Too High.”

    Notes for Abstraction:

      • For the lipid measurements, enter the highest value measured within the first 48 hours after arrival or within 30 days prior to hospital arrival. Fasting and non-fasting LDL-c values are both acceptable.(1)
      • If the first lipid values available are measured greater than 48 hours after arrival, select “Lipids: ND”. Do not enter values measured after 48 hours.
      • For patients whose triglycerides are >400 mg/dL, enter the values for total cholesterol, HDL and triglycerides, BUT leave the LDL value blank. EXCEPTION: If your hospital has the capability to directly measure LDL levels and this is available to you, enter that value.
      • If triglycerides are < 400 mg/dL, LDL can be calculated from the following formula:
        LDL = Total Cholesterol - (HDL + (Triglycerides / 5)). However, if triglycerides are >= 400 mg/dL, this formula cannot be used to compute LDL.
      • For the A1C measurement, enter the first value measured or if available within 30 days in the outpatient record for diabetics.
      • For Blood Glucose (mg/dL), enter the first measurement upon arrival to your hospital. If supplemental glucose was given prior to hospital arrival, enter the blood glucose level obtained in the pre-hospital setting prior to the provision of glucose if that level is available. Blood Glucose is a required data element for patients that receive IV alteplase.
      • If an outpatient value is available within 30 days for lipids and another lipid panel is measured in the hospital within 48 hours of arrival enter the more recent values.
      • For inpatient strokes:
        • Only enter lipids measured within 48 hours of actual arrival or if available as a fasting sample within 30 days in the outpatient record.
        • A1C and blood glucose should be the first values measured upon arrival to your hospital.

    Example: Patient 270a arrived in your ED on 7/25/2011. A non-fasting sample for lipid testing was drawn in the ED on arrival. A second fasting sample was taken on 7/29/2011. Enter the values obtained from the ED as the non fasting sample is acceptable and the second sample was drawn greater than 48 hours after arrival.

      Hospitalization Data

      (1)
      Gore JM, Goldberg RJ, Matsumoto AS, et al. Validity of serum total cholesterol level obtained within 24 hours of acute myocardial infarction. Am J Cardiol. 1984;54:722-725.
      Van Dis FJ, Keilson LM, Rundell CA, et al. Direct measurement of serum low-density lipoprotein cholesterol in patients with acute myocardial infarction on admission to the emergency room. Am J Cardiol. 1996;77:1232-1234.
      Craig SR, Amin RV, Russell DW, Paradise NF. Blood cholesterol screening influence of fasting state on cholesterol results and management decisions. J Gen Intern Med. 2000 Jun;15(6):395-9.
      Weiss R, Harder M, Rowe J. The relationship between nonfasting and fasting lipid measurements in patients with or without type 2 diabetes mellitus receiving treatment with 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors. Clin Ther. 2003 May;25(5):1490-7.
      Pitt B, Loscalzo, Ycas J, Raichlen JS. Lipid Levels After Acute Coronary Syndromes. J Am Coll Cardiol 2008;51;1440-1445.

      Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

      Data Element Name: Initial Blood Glucose Value at Hospital Arrival

      Collected For: CSTK-05, CSTK-08

      Definition: Documentation of the first blood glucose value obtained prior to or after hospital arrival. A blood glucose test measures the amount of a type of sugar, called glucose, in the blood.

      Suggested Data Collection Question: What is the first blood glucose value obtained prior to or after hospital arrival?

      Format

      Length:
      3
      Type: Alphanumeric
      Occurs:1

      Allowable Values:
      BG= blood glucose value (no decimals)
      UTD = Unable to Determine

      Notes for Abstraction:

      • To determine the value for this data element, review the blood glucose values obtained prior to and after hospital arrival.
      • Select the earliest documented blood glucose value regardless of location of testing. Values obtained and documented by EMS, a transferring hospital, or your hospital are acceptable.
        The first documented value should be used.
      • Values obtained with point-of-care (POC) devices, finger-stick, or laboratory values are acceptable.

      Suggested Data Sources:

      • Emergency department record
      • History and physical
      • Nursing flow sheet
      • Progress notes
      • Transfer sheet
      • Admitting note
      • Ambulance record
      • Consultation form/note
      • Nursing assessment
      • EMS records

      Excluded Data Sources:

      • Discharge Summary

      Guidelines for Abstraction

      Inclusion: None
      Exclusion: None

    Summary of Changes

    OPTIONAL: Serum Creatinine

    Enter the patient's Serum Creatinine value in units of mg/dL. Enter the patient's first measurement upon presentation to your hospital.

    Notes for Abstraction:

    • It is often abbreviated as Cr. It is part of the standard set of blood chemistries (e.g. electrolytes) typically ordered when patients arrive at the hospital. It is different from urine creatinine, and also creatine phosphokinase (CPK) which is frequently measured to exclude heart attack. It is often reported out with the Blood Urea Nitrogen (BUN) value and typically ranges from 0.8 - 1.4 mg/dL in healthy individuals. Enter the number rounded to one decimal point.
    • For inpatient strokes, enter the first value measured upon presentation to your hospital.

    Hospitalization Data

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: What is the first platelet count obtained prior to or after hospital arrival?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Initial Platelet Count at Hospital Arrival

    Collected For: CSTK-05, CSTK-08

    Definition: Documentation of the first platelet count obtained prior to or after hospital arrival. Platelets are one of three components of human blood. Platelets play a very important role in the healing process and the formation of blood clots at the time of injury.

    Suggested Data Collection Question: What is the first blood glucose value obtained prior to or after hospital arrival?

    Format

    Length:
    6 (no comma, no decimal)
    Type: Alphanumeric
    Occurs:1

    Allowable Values:
    PLT = platelet count value (no commas, no decimal)
    UTD = Unable to Determine

    Notes for Abstraction:

    • To determine the value for this data element, review the platelet counts obtained prior to and after hospital arrival.
    • Select the earliest documented platelet count regardless of location of testing. Values obtained and documented by EMS, a transferring hospital, or your hospital are acceptable. The first documented platelet count should be used.
    • Platelet counts obtained with point-of-care (POC) devices or laboratory values are acceptable.

    Suggested Data Sources:

    • History and physical
    • Nursing flow sheet
    • Progress notes
    • Transfer sheet
    • Admitting note
    • Ambulance record
    • Consultation form/note
    • Emergency room records
    • Nursing assessment
    • EMS records

    Excluded Data Sources:

    • Discharge Summary

    Guidelines for Abstraction

    Inclusion: None
    Exclusion: None

    Summary of Changes

    OPTIONAL: INR

    International Normalized Ratio (INR). This numerical value reflects the degree of anticoagulation for patients on long-term warfarin therapy. It is not valid for patients who are currently receiving argatroban. Enter the number rounded to one decimal point.

    • INR value
    • NC - Select NC for patients currently receiving argatroban
    • ND

    Notes for Abstraction:

    Hospitalization Data

    Summary of Changes

    REQUIRED FOR COMPREHENSIVE: Is there documentation in the medical record that the INR value performed closest to hospital arrival was greater than 1.4?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: INR Value > 1.4

    Collected For: CSTK-04

    Definition: Documentation that the international normalized ratio (INR) value performed closest to hospital arrival was greater than 1.4. This value correlates to the ability of the blood to clot. Higher values greater than 1.4 are associated with an increased risk of hemorrhage.

    Suggested Data Collection Question: Is there documentation in the medical record that the INR value performed closest to hospital arrival was greater than 1.4?

    Format

    Length:
    1
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:

    Y (Yes) There is documentation that the INR value performed closest to hospital arrival was greater than 1.4.

    N (No) There is no documentation that the INR value performed closest to hospital arrival was greater than 1.4, OR unable to determine from medical record documentation.

    Notes for Abstraction:

    • To determine the value for this data element, review the INR values obtained closest to hospital arrival (i.e., before and after hospital arrival). If any result is greater than 1.4, select "Yes".
    • INR values obtained at a transferring hospital may be used to select 'YES' if a more recent INR value was not done after arrival at this hospital.

    Suggested Data Sources:

    • Emergency department record
    • Laboratory report
    • Nursing notes
    • Progress notes
    • Transfer sheet

    Guidelines for Abstraction

    Inclusion: None
    Exclusion: None

    Summary of Changes

    OPTIONAL COMPREHENSIVE: If initial INR > 1.4 and treated with procoagulant, Date/Time first INR <= 1.4 after treatment

    Enter the first date/time recorded after treatment with procoagulant that the INR is less than or equal to 1.4. If there is no documentation of an INR value less than 1.4 after treatment with procoagulant, leave this data element blank.

    • Date:MM/DD/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    Hospitalization Data

    OPTIONAL: Vital Signs: Heart Rate and Blood Pressure

    Enter the patient's Heart Rate in beats per minute and Blood Pressure (systolic/diastolic) in mmHg. Enter the patient's first measurement upon presentation to your hospital. Blood pressure is a required data element for patients that receive IV alteplase.

    Notes for Abstraction:

    • For inpatient strokes, enter the first heart rate and blood pressure obtained after discovery of stroke symptoms.

    Hospitalization Data

    REQUIRED FOR COMPREHENSIVE: What is the first blood pressure obtained prior to or after hospital arrival?

    Element definition from The Joint Commission Comprehensive Stroke Performance Measurement Implementation Guide

    Data Element Name: Initial Blood Pressure at Hospital Arrival

    Collected For: CSTK-05, CSTK-08

    Definition: Documentation of the first blood pressure (systolic and diastolic values) obtained prior to or after hospital arrival. Systolic blood pressure is the amount of pressure that blood exerts on vesseles while the heart is beating. In a blood pressure reading (e.g., 120/80), it is the number on the top. The diastolic blood pressure number or the bottom number indicates the pressure in the arteries when the heart rests between beats. A normal diastolic blood pressure number is less than 80.

    Suggested Data Collection Question: What is the first blood pressure obtained prior to or after hospital arrival?

    Format

    Length:
    7
    Type: Alphanumeric
    Occurs: 1

    Allowable Values:
    BP = systolic and diastolic blood pressure values
    UTD = Unable to Determine

    Notes for Abstraction:

    • To determine the value for this data element, review blood pressure readings obtained prior to and after hospital arrival.
    • Select the earliest documented blood pressure regardless of where it was done. Blood pressure readings obtained and documented by EMS, a transferring hospital, or your hospital are acceptable. The first documented blood pressure should be used.

    Suggested Data Sources:

    • History and physical
    • Nursing flow sheet
    • Progress notes
    • Transfer sheet
    • Admitting note
    • Ambulance record
    • Consultation form/note
    • Emergency room records
    • Nursing assessment
    • EMS records

    Excluded Data Sources:

    • Discharge Summary

    Guidelines for Abstraction

    Inclusion: None
    Exclusion: None

    Summary of Changes

    OPTIONAL: Height, Weight, Waist Circumference, and BMI

    Height, Weight, and BMI - REQUIRED for Target: Type 2 Diabetes with hx of DM or new diagnosis

    Enter the patient's height and weight. Indicate if these are measured in inches, cm or lbs, kg respectively. BMI will be calculated by the computer. If height/weight information is not documented, select ND. Waist circumference is the distance around the patient's waist (measured horizontally at the iliac crest). The goal for waist circumference is less than 40 inches for men and less than 35 inches for women.

    Hospitalization Data


    Discharge Tab

    Discharge Information

    REQUIRED: Discharge Date and Time (Date and Time of discharge from hospital)

    Record the month, day, and year the patient was discharged from acute care, left against medical advice, or expired during this stay.

    • Date:MM/DD/YYYY
    • Time: HH:MM
    • 24-hour clock (military time)

    Notes for Abstraction:

    • Because this data element is critical in determining the population for all measures, the abstractor should NOT assume that the claim information for the discharge date is correct. If the abstractor determines through chart review that the claim date is incorrect, she/he should correct and override the downloaded value. If the abstractor is unable to determine the correct discharge date through chart review, she/he should default to the claim discharge date.
    • The discharge date is the day that the patient is discharged from your institution's acute care unit OR the date of the patient's expiration OR the date of the patient's discharge OR date patient left against medical advice (AMA) OR date of transfer to, a rehabilitating, skilled nursing, or hospice unit in your institution OR transfer to an acute in-patient unit outside of your own institution, even if that hospital is affiliated with your own OR expired. If the patient is never admitted to your facility (i.e. you answered the data element of “Not Admitted” as “Yes, Not Admitted” enter the date of discharge from the ED or observation unit.”

    Administrative Data: ,UB-04, Field Location: 6, Medical Record: Discharge summary, face sheet, nursing discharge notes, physician orders, progress notes, transfer notes.

    Summary of Changes

    OPTIONAL: Get With The Guidelines® Ischemic Stroke-Only Estimated Mortality Rate

    Calculation of predicted probability of in-hospital death based on stroke patient risk factors present on admission. This reported percentage represents the individual patient's predicted risk for in-hospital mortality. It is calculated based on the following risk factors at the time of hospital presentation: age, gender, arrival mode, medical history, date and time of arrival, and NIHSS (if present). This predicted probability formula was derived and validated using the Get With The Guidelines®-Stroke database using a model that is applicable only to Ischemic stroke patients. This risk prediction is intended to enhance not replace clinical assessment and physician judgment. If too many of the necessary variables are missing, the mortality rate cannot be calculated for the patient.

    Any of the following cases will exclude the calculation of a risk score:

    • Patient was transferred from another hospital
    • Patient was transferred from your ED to another acute care hospital
    • Final clinical diagnosis related to stroke is TIA or no stroke related diagnosis
    • Patient received IV alteplaseA at an outside hospital
    • First NIH Stroke Scale total score recorded by hospital personnel is greater than 42

    Summary of Changes

    OPTIONAL: Get With The Guidelines® Global Stroke Estimated Mortality Rate (Ischemic Stroke, SAH, ICH, Stroke not otherwise specified)

    Calculation of predicted probability of in-hospital death based on stroke patient risk factors present on admission. This reported percentage represents the individual patient's predicted risk for in-hospital mortality. It is calculated based on the following risk factors at the time of hospital presentation: age, gender, arrival mode, stroke type, medical history, date and time of arrival, and NIHSS (if present). This predicted probability formula was derived and validated using the Get With The Guidelines®-Stroke database using a model that includes all stroke types. This risk prediction is intended to enhance not replace clinical assessment and physician judgment. If too many of the necessary variables are missing, the mortality rate cannot be calculated for the patient.

    Any of the following cases will exclude the calculation of a risk score:

    • Patient was transferred from another hospital
    • Patient was transferred from your ED to another acute care hospital
    • Final clinical diagnosis related to stroke is TIA or no stroke related diagnosis
    • Patient received IV alteplase at an outside hospital
    • First NIH Stroke Scale total score recorded by hospital personnel is greater than 42

    Summary of Changes

     

    Modified Rankin Scale at discharge
    Required field for GWTG - Stroke

    Definition: Documentation in the medical record of a Modified Rankin Scale (mRS) completed at time of discharge. The Modified Rankin Score (mRS) is a 6- point disability scale with possible scores ranging from 0 to 5. A separate category of 6 is usually added for patients who expire.

    Data Collection Question: Was a Modified Rankin Scale (mRS) performed at discharge?

    Format: Single-select field

    Allowable Values:

    • Yes: A Modified Rankin Scale was performed at discharge
    • No/ND: A Modified Rankin Scale was not performed or was performed but the total score is not available.

    Notes for Abstraction:

    • This mRS assessment is intended to measure disability at the time of discharge. If there is more than 1 measured, use the mRS measured closest to hospital discharge. Ideally the mRS will be measured at discharge.
    • If a mRS measurement has not been documented in the medical record, but sufficient information is available from the physical therapy (PT) notes, occupational therapy (OT) notes, and/or other sources to allow a mRS to be assigned retrospectively assigned mRS score may be entered into the case report form. Select "Yes" to this data element and enter the findings under Total Score.
    • If the mRS is not measured or documented and a mRS cannot be assigned retrospectively, then select "No/ND."
    • It is highly recommended that the mRS be measured by certified individuals.
    • Two formal scoring methods for the mRS are the Simplified Questionnaire (SQ) and the Rankin Focused Assessment (RFA).
      • The Simplified Questionnaire may not be the most appropriate for use in the pre-discharge setting.
      • The more detailed Rankin Focused Assessment may be more appropriate for use at post-discharge visits, but also may be helpful to use selectively for cases in which pre-discharge scoring based on the SQ is uncertain.

    Suggested Data Sources:

    • Admission Data
    • Hospitalization Data

    If Yes, (Modified Rankin Scale Collected at Discharge)

    Optional field for GWTG – Stroke

    Note: Field is only enabled if “Modified Rankin Score at Discharge” = YES. Else, field will be grayed out.

    Definition:  If there was documentation in the medical record of a Modified Rankin Score (mRS) completed at time of discharge, indicate method that was used to obtain the score at the time of discharge.

    Data Collection Question: What method was used to obtain the mRS score at the time of discharge?

    Format:  Single-select field

    Allowable Values

    • Actual: mRS score was documented in the record as the result of the scale being performed
    • Estimated from the record: mRS score was reconstructed retrospectively
    • ND: The method of mRS score calculation was not documented

    Notes for Abstraction:

    • If a Modified Rankin Scale score is present in eCRF (PMT) what method was used to obtain the score recorded.

    Suggested Data Sources:

    • Admission Data
    • Hospitalization Data

    Total Score

    Required Field only if “Modified Rankin Score at Discharge” = YES. Else, field will be grayed out.

    Definition: If a Modified Rankin Scale was measured at discharge, record the total score for this patient. Click on (Show/Hide) to display the scale.

    Data Collection Question: What is the total score recorded by hospital personnel closest to discharge?

    Format: Text Field (numeric values)

    Allowable Values:

    • 0 – 6
    • The values 0-6 correspond to the mRS documented at time of discharge:
    • 0 =No disability
    • 1 =No significant disability: despite symptoms: able to carry out all usual duties and activities.
    • 2 =Slight disability: unable to carry out all routine activities but able to look after own affairs without assistance.
    • 3 =Moderate disability: requiring some help, but able to walk without assistance.
    • 4 =Moderately severe disability: unable to walk without assistance, and unable to attend to own bodily needs without assistance.
    • 5 =Severe disability: bedridden, incontinent and requiring constant nursing care and attention.
    • 6 =Dead

    Notes for Abstraction:

    • Modified Rankin Score (mRS) may be documented by the physician/APN/PA, nurse (RN), medical assistant, or any individual trained to perform the mRS.
    • No value should be recorded more than once

    Suggested Data Sources:

    • Discharge Data

    Ambulatory status at discharge?

    Required for Coverdell

    Definition: Indicate the patient's ambulatory status at discharge.

    Data Collection Question: What was patient's ambulatory status at discharge?

    Format: Single-select field

    Indicate the patient's ambulatory status at discharge.

    • Able to ambulate independently (no help from another person) w/or w/o device
    • With assistance (from person)
    • Unable to ambulate
    • ND

    Notes for Abstraction:

    • Able to ambulate independently (no help from another person) w/or w/o device: Patient ambulating without assistance (no help from another person) with or without a device. This means patient is able to ambulate without help from another person. The use of a device, such as a cane, still meets this definition. Patient ambulating to and from the bathroom unassisted. Even though actual ambulation is not documented in the medical record, privileges to walk to and from the bathroom and evidence of the patient getting out of bed unassisted are considered to meet the definition of ambulation.
    • With assistance (from person): Patient ambulating with assistance of another person.
    • Unable to ambulate: Patient is on bedrest. Patient is only getting out of bed to the bedside commode (or up in chair) and is primarily in the bed (or immobile) at discharge
    • ND: If it is unable to determine from documentation.
    • Examples: Patient 310a is ambulating with assistance from nursing. There is documented evidence of the patient walking around the unit with assistance from his nurses. Choose "With assistance (from person)."

    Suggested Data Sources:

    • Hospitalization Data
    • Discharge Data

    Discharge Blood Pressure (Measurement closest to discharge)

    Optional Field

    Definition: Intent of the element is to capture if the patient’s BP is within the normal range based on the AHA Guidelines. Record the patient’s last blood pressure reading taken prior to discharge from hospital.

    Data Collection Question: What was the patient’s last blood pressure prior to deing discharge from the hospital?

    Format: Text fields

     Allowable Values:

    • Numeric values
    • ND

     Notes for Abstraction:

    • Unit of measurement: mmHg
    • Enter the value for systolic in the first field
    • Enter the systolic in the second field

     Suggested Data Sources:

    • Discharge Data
    • Hospitalization Data

    Discharge Treatments

      General Instructions for these sections:
      • If the discharge destination is expired or "left against medical advice" or Hospice, these fields will be pre-selected as NC or "None - contraindicated". If the patient did not receive a medication at discharge due to a contraindication, or if the treatment was not indicated (i.e., not applicable) for the patient in question, or if the patient refused, select NC or "None - contraindicated".
      • If a patient is discharged with instructions that a medication will be started at a follow-up visit, select No.
      • If the reason for non-treatment specifically documents a contraindication, select NC or "None - contraindicated".
         Examples:
      • Patient 320a was admitted to your facility with an ischemic stroke. On discharge he was given a prescription for Coumadin and it is documented in the record that he is not to start the medication for one week due to an increased risk of bleeding. Data entry for antithrombotic medication at discharge would be None-contraindicated or NC.
      • Patient 320b was admitted to your facility with an ischemic stroke. His LDL was found to be 130. The patient had some issues with elevated LFTs and the physician writes in the medical record that he will start the patient on a cholesterol reducing medication in a follow up appointment after discharge given the patients LFTs. Data entry for cholesterol reducing medication at discharge would be None-contraindicated or NC.

    Hospitalization Data, Discharge Data

    Summary of Changes

    REQUIRED: Antithrombotic Therapy approved in stroke

    Prescribed: Was antithrombotic medication approved in stroke prescribed at discharge?

    • Yes: Antithrombotic therapy was prescribed at hospital discharge (see inclusion list below).
    • No/ND: Antithrombotic therapy was not prescribed at hospital discharge, OR an alternate antithrombotic not on the list was prescribed at discharge, OR unable to determine from medical record documentation
    • NC: There is documentation in the medical record of a reason for not prescribing an antithrombotic therapy on the list below at hospital discharge

    Notes for Abstraction:

    • See Table 4 & Table 5 for a list of antithrombotic medications. Antithrombotics include both anticoagulant and antiplatelet drugs.
    • Select "Yes" only if one of the following antithrombotic medications was prescribed at discharge.

        Antiplatelet Inclusion:

        Anticoagulant Inclusion:

        Aspirin

        Apixaban (Eliquis)

        Aspirin/dipyridamole (Aggrenox)

        Argatroban

        Clopidogrel (Plavix)

        Dabigatran (Pradaxa)

        Ticlopidine (Ticlid)

        Edoxaban (Savaysa)

         

        Fondaparinux (Arixtra)

        Full dose LMW heparin

        Lepirudin (Refludan)

        Rivaroxaban (Xarelto)

        Unfractionated heparin IV

        Warfarin (Coumadin)

        • In determining whether antithrombotic therapy was prescribed at discharge, it is not uncommon to see conflicting documentation amongst different medical record sources. For example, the discharge summary may list an antithrombotic that is not included in any of the other discharge medication sources (e.g., discharge orders). All discharge medication documentation available in the chart should be reviewed and taken into account by the abstractor.
        • In cases where there is an antithrombotic in one source that is not mentioned in other sources, it should be interpreted as a discharge medication (select "Yes") unless documentation elsewhere in the medical record suggests that it was NOT prescribed at discharge - Consider it a discharge medication in the absence of contradictory documentation.
        • If documentation is contradictory (e.g., physician noted “d/c Plavix” in the discharge orders, but Plavix is listed in the discharge summary’s discharge medication list), or after careful examination of circumstances, context, timing, etc., documentation raises enough questions, the case should be deemed "unable to determine" (select "No").
        • Consider documentation of a hold on an antithrombotic after discharge in one location and a listing of that antithrombotic as a discharge medication in another location as contradictory ONLY if the timeframe on the hold is not defined (e.g., “Hold Plavix”). Examples of a hold with a defined timeframe include “Hold Plavix x2 days” and “Hold ASA until after stress test.”
        • If an antithrombotic is NOT listed as a discharge medication, and there is only documentation of a hold or plan to delay initiation/restarting of antithrombotic therapy after discharge (e.g., “Hold Plavix x2 days,” “Start Plavix as outpatient,” “Hold Plavix”), select “No”.
        • If two discharge summaries are included in the medical record, use the one with the latest date/time. If one or both are not dated or timed, and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Use the dictated date/time over transcribed date/time, file date/time, etc.
        • Examples:

        • Two discharge summaries, one dictated 5/22 (day of discharge) and one dictated 5/27 - Use the 5/27 discharge summary.
        • Two discharge medication reconciliation forms, one not dated and one dated 4/24 (day of discharge) - Use both.
        • Disregard an antithrombotic medication documented only as a recommended medication for discharge (e.g., “Recommend sending patient home on aspirin”). Documentation must be clearer that an antithrombotic was actually prescribed at discharge.
        • Disregard documentation of antithrombotic prescribed at discharge when noted only by medication class (e.g., “Antithrombotic Prescribed at Discharge: Yes” on a core measures form). The antithrombotic must be listed by name.
        • Prasugrel (Effient) is contraindicated in post ACS/PCI patients with stroke or TIA and is NOT considered an acceptable antithrombotic (antiplatelet) therapy for stroke prevention treatment. If Prasugrel (Effient) is the only antithrombotic medication prescribed at discharge, select “No/ND” here and answer the subsequent data element of "Other Antithrombotic(s) - Prescribed" = "Yes" and choose Prasugrel from the drop down.
          • EXCEPTION: If Prasugrel (Effient) is prescribed in addition to aspirin, select “Yes” for antithrombotic prescribed at discharge. Note the abstractor should select “Antiplatelet” class and “Aspirin” under medication. The subsequent data element of "Other Antithrombotic(s) - Prescribed" should also be answered as "Yes" and Prasugrel should be selected from the drop down.
        • Reasons for not prescribing antithrombotic therapy at hospital discharge must be documented by a physician/APN/PA or pharmacist.
        • If reasons are not mentioned in the context of antithrombotics, do not make inferences (e.g., do not assume that antithrombotic therapy was not prescribed because of a bleeding disorder unless documentation explicitly states so).
          • Reasons must be explicitly documented (e.g., Active GI bleed – antithrombotic therapy contraindicated”, “No ASA” [no reason given].).
          • Physician/APN/PA or pharmacist documentation of a hold on an antithrombotic medication or discontinuation of an antithrombotic medication that occurs during the hospital stay constitutes a “clearly implied” reason for not prescribing antithrombotic therapy at discharge. A hold/discontinuation of all p.o. medications counts if an oral antithrombotic medication (e.g., Plavix) was on order at the time of the notation.
            EXCEPTIONS:
            • Documentation of a conditional hold or discontinuation of an antithrombotic medication (e.g., “Hold ASA if guaiac positive”, “Stop plavix if rash persists,” “No ASA for 24 hours following thrombolytic therapy”).
            • Discontinuation of a particular antithrombotic medication documented in combination with the start of a different antithrombotic medication (i.e., switch type of antithrombotic medication) does not count as a reason for not prescribing an antithrombotic medication at discharge.
              Examples:
                - “Stop Plavix” and “Start Plavix 75 mg po daily” in same physician order
                - “Change Plavix to aspirin” in progress note
                - “Do not continue after discharge” checked for Plavix and “Continue after discharge” checked for clopidogrel on a physician-signed discharge medication reconciliation form
            • Discontinuation of an antithrombotic medication at a particular dose documented in combination with the start of a different dose of that antithrombotic (i.e., change in dosage) does not count as a reason for not prescribing an antithrombotic medication at discharge.
              Examples:
                - “Stop Ecotrin 300 mg po daily” and “Start Ecotrin 325 mg po daily” in same physician order
                - “Increase Ectotrin 81 mg to 325 mg daily” in progress note
                - “Do not continue after discharge” checked for Ecotrin 300 mg and “Continue after discharge” checked for Ecotrin 325 mg on a physician-signed discharge medication reconciliation form
          • Deferral of antithrombotic therapy from one physician/APN/PA or pharmacist to another does NOT count as a reason for not prescribing antithrombotic therapy at discharge unless the problem underlying the deferral is also noted.
            Examples:
            - “Consulting neurologist to evaluate pt. for warfarin therapy.” – DO NOT select “NC”.
            - “Rule out GI bleed. Start ASA if OK with neurology.” - select “NC”.
          • If there is documentation of a plan to initiate/restart antithrombotic therapy, and the reason/problem underlying the delay in starting/restarting antithrombotic therapy is also noted, this constitutes a “clearly implied” reason for not prescribing antithrombotic therapy at discharge.
            • Acceptable examples (select “NC”):
                - “Stool Occult Blood positive. May start Coumadin as outpatient.”
                - “Start ASA if hematuria subsides.”
            • Unacceptable examples (DO NOT select “NC”):
                - “Consider starting Coumadin in a.m.”
                - “May add Plavix when pt. can tolerate”
          • Reasons do NOT need to be documented at discharge or otherwise linked to the discharge timeframe: Documentation of reasons anytime during the hospital stay are acceptable (e.g., mid-hospitalization note stating “no ASA due to rectal bleeding” - select “NC,” even if documentation indicates that the rectal bleeding has resolved by the time of discharge and ASA was restarted).
          • Crossing out of an antithrombotic medication counts as a "clearly implied reason" for not prescribing antithrombotic therapy at discharge only if on a pre-printed form.
        • An allergy or adverse reaction to one type of antithrombotic would NOT be a reason for not administering all antithrombotics. Another medication can be ordered.
        • When conflicting information is documented in the medical record, select “NC.”
        • When the current record includes documentation of a pre-arrival reason for no antithrombotic therapy, the following counts regardless of whether this documentation is included in a pre-arrival record made part of the current record or whether it is noted by hospital staff during the current hospital stay:
          • Pre-arrival hold/discontinuation or notation such as "No Coumadin" IF the underlying reason/problem is also noted (e.g., “Coumadin held in transferring hospital due to possible GI bleed”).
          • Pre-arrival "other reason" (other than hold/discontinuation or notation of "No ASA") (e.g., "Hx GI bleeding with ASA" in transferring ED record).
        • Acceptable reasons for not giving antithrombotic medication at hospital discharge may include:
          • Allergy to or complication related to antithrombotic
          • Serious side effect to medication
          • Aortic dissection
          • Bleeding disorder
          • Brain/CNS cancer
          • CVA, hemorrhagic
          • Extensive/metastatic CA
          • Hemorrhage, any type
          • Intracranial surgery/biopsy
          • Patient/family refusal
          • Peptic ulcer
          • Planned surgery within 7 days following discharge
          • Risk of bleeding or discontinued due to bleeding
          • Unrepaired intracranial aneurysm
          • Terminal Illness
          • Other documented by physician/APN/PA or pharmacist

        Please note: Anticoagulants at doses (low dose) designed to prevent deep vein thrombosis are insufficient as antithrombotic therapy to prevent recurrent ischemic stroke or TIA. Conversely, antiplatelet agents at doses to prevent recurrent ischemic stroke or TIA are insufficient therapy to prevent deep vein thrombosis. However, anticoagulants at full therapeutic doses (such as full dose LMW heparin, unfractionated heparin IV, or warfarin) are considered acceptable treatment options for both DVT prophylaxis and antithrombotic medication.

        • DVT prevention doses may include:
          • dalteparin (Fragmin): 2500 or 5000 units SQ every day
          • enoxaparin (Lovenox): 30-40 mg SQ every day or 2 times a day
          • fondaparinux (Arixtra): 2.5 mg SQ every day
          • Heparin: 5000 units SQ every 8-12 hrs
          • rivaroxaban (Xarelto) Oral: 10 mg every day for prevention of DVT after hip surgery
        • Therapeutic doses, that may prevent DVT and also be effective as therapeutic anticoagulation to prevent stroke, may include:These doses are provided to aid chart abstraction and not as an endorsement of any of the specific medicines for treatment or prevention of stroke. In many cases these medicines are not approved by the FDA for treatment or prevention of stroke, but could reasonably be used off-label for that purpose.
          • apixaban (Eliquis): 5mg twice daily (2.5 mg twice daily in patients with two or more of the following: age >/= 80 years, weight </= 60kg, or serum creatinine >/= 1.5mg/dL)
          • argatroban at any dose IV infusion
          • dabigatran (Pradaxa): 150 mg 2 times a day (75 mg 2 times a day in patients with renal failure)
          • dalteparin (Fragmin) : 100 IU/kg SQ every 12hrs
          • fondaparinux (Arixtra): 5-10 mg SQ every day
          • Heparin: continuous IV infusion titrated to elevated PTT outside the normal range. Typical ranges could include PTT 50-70 or 60-84; however, IV heparin is not of proven benefit for acute ischemic stroke or secondary prevention of stroke.
          • lepirudin (Refludan) at any dose IV infusion
          • rivaroxaban (Xarelto) Oral: 20 mg every day (15 mg every day in patients with renal failure)

        If "Yes" is selected, a class (Antiplatelet or Anticoagulant) and medication is required.
        Recording the dosage and frequency are OPTIONAL.

        Examples:

        • Patient 330a is admitted to the in-patient unit following treatment with thrombolytic therapy. He is discharged on day 5 with instructions to start aspirin in one week due to the risk of bleeding from his large stroke. Data Entry will be to check NC.
        • Patient 330b is admitted with new onset atrial fibrillation and a minor stroke. He is discharged on dalteparin 100 IU/kg sq twice a day along with a plan to start warfarin in 7 days. Data Entry will be to check YES.
        • Patient 330c is admitted with new onset atrial fibrillation and a minor stroke. He is discharged on enoxaparin 40 mg sq daily for DVT prophylaxis. Data Entry will be to check NO.

        Hospitalization Data, Discharge Data

        Summary of Changes

        REQUIRED: Antiplatelet: See Table 4 for a list of antiplatelet medications.

        Check the box if the patient was prescribed an antiplatelet medication at discharge.

        REQUIRED: Antiplatelet Medication (Specify):

        If antiplatelet was prescribed at discharge, select the specific medication.

          • Aspirin
          • Aspirin/Dipyridamole (in separate formulations or as Aggrenox)
          • Clopidogrel (Plavix)
          • Ticlopidine (Ticlid)

        Recording the dosage and frequency are OPTIONAL.

        REQUIRED: Anticoagulant: See Table 5 for a list of anticoagulant medications

        Check the box if the patient was prescribed an anticoagulant medication at discharge.

        REQUIRED: Anticoagulant Medication (Specify):

          • Unfractionated heparin IV
          • Full dose LMW heparin
          • Warfarin (Coumadin)
          • dabigatran (Pradaxa)
          • argatroban
          • fondaparinux (Arixtra)
          • lepirudin (Refludan)
          • rivaroxaban (Xarelto)
          • edoxaban (Savaysa)

        Hospitalization Data, Discharge Data

        Summary of Changes

        OPTIONAL: If NC, documented contraindications (Select all that apply)

        Select the specific reason(s) documented for not prescribing antithrombotic therapy at discharge.

        • Allergy to or complication related to aspirin, ticlopidine, clopidogrel, dipyridamole, warfarin or heparins (hx or current)
        • Patient/Family refused
        • Risk for bleeding or discontinued due to bleeding
        • Serious side effect to medication
        • Terminal illness/Comfort Measures Only
        • Other

        Notes for Abstraction

        • Reasons for not prescribing antithrombotic therapy must be documented by a physician, advance practice nurse or physician assistant.
        • If reasons are not mentioned in the context of antithrombotics, do not make inferences (e.g., do not assume that antithrombotics are not being prescribed because of a bleeding disorder unless documentation explicitly states so.)
        • It is not intended that this list of reasons is inclusive of all possible reasons for not prescribing antithrombotic at discharge. Select if any of these were documented as reasons for not prescribing antithrombotic therapy at discharged.

        Hospitalization Data, Discharge Data

        Summary of Changes

        OPTIONAL: Other Antithrombotic(s) Prescribed:

        Was an antithrombotic medication not on the "Antithrombotic Therapy approved in stroke" list (an alternate antithrombotic medication) prescribed at discharge?

        • Yes: An alternate antithrombotic therapy was prescribed at hospital discharge
        • No: An alternate antithrombotic therapy was not prescribed at hospital discharge, OR unable to determine from medical record documentation

        OPTIONAL: If yes, Medication

        Other Antithrombotic(s) Medication (Specify Medication, Dosage, and Frequency):

          • Desirudin (Iprivask)
          • Ticagrelor (Brilinta)
          • Prasugrel (Effient)
          • Other

          Notes for Abstraction:

          • Therapeutic doses, that may prevent DVT and also be effective as therapeutic anticoagulation to prevent stroke, may include: these doses are provided to aid chart abstraction and not as an endorsement of any of the specific medicines for treatment or prevention of stroke. In many cases these medicines are not approved by the FDA for treatment or prevention of stroke, but could reasonably be used off-label for that purpose.
            • desirudin (Iprivask): 15 mg every 12 hours

        REQUIRED: Persistent or Paroxysmal Atrial Fibrillation/Flutter (Was atrial fibrillation/flutter or paroxysmal atrial fibrillation (PAF), documented during this admission?)

        Any evidence of atrial fibrillation or flutter observed or identified during the hospital admission. The medical record should contain documentation by a physician or other provider which describes the episode OR EKG/monitor finding of atrial fibrillation or flutter. This includes persistent or paroxysmal fibrillation/flutter.

        • Yes
        • No

        Notes for Abstraction:

        • Documentation of atrial fibrillation or flutter on current EKG, select “Yes”.
        • Diagnosis of current atrial fibrillation or flutter anywhere in the medical record, select “Yes”.
        • See the inclusion list for acceptable examples of documentation. The list is not all-inclusive.

        Inclusion Guidelines for Abstraction:

        • AF
        • A-fib
        • Atrial fibrillation
        • Atrial flutter
        • Persistent atrial fibrillation
        • Paroxysmal atrial fibrillation
        • PAF

        Examples:

        • Patient 340a had no prior history of atrial fibrillation. They are admitted with an ischemic stroke and new onset atrial fibrillation is documented in the ED. The patient is discharged on Coumadin for non-valvular atrial fibrillation. Data entry will be to select "Yes" for Persistent or Paroxysmal Atrial Fibrillation/Flutter (Data entry for Previously known medical history is NOT to check Atrial Fib/Flutter).
        • Patient 340b was admitted with the diagnosis of acute ischemic stroke, a history of paroxysmal atrial fibrillation, but the EKG in the ED shows sinus rhythm. Holter monitor during the hospitalization does not show evidence of atrial fibrillation. Data entry will be to select "No" for Persistent or Paroxysmal Atrial Fibrillation/Flutter. (Data entry for Previously known medical history is to check Atrial Fib/Flutter)
        • Patient 340c was admitted with the diagnosis of acute ischemic stroke and a remote history of a brief period of self-limited atrial fibrillation after bypass surgery 6 years ago and negative Holter monitoring in the years since. The patient is in sinus rhythm and on no current management for AF. There is no evidence of atrial fibrillation during the hospitalization. (Data entry for Previously known medical history is NOT to check Atrial Fib/Flutter and "No" for Persistent or Paroxysmal Atrial Fibrillation/Flutter. )

        Admission Data, Hospitalization Data, (includes: EKG report, Holter monitor report, rhythm strip with documented interpretation of atrial fibrillation/flutter, transfer sheet), Discharge Data

        Summary of Changes

        REQUIRED: If atrial fib/flutter or history of PAF documented, was patient discharged on anticoagulation?

        Patients with Atrial fib/flutter are at increased risk for stroke. This includes patients who have afib or flutter during the hospital stay or patients who have a history of any Afib/Flutter including PAF documented in the medical record, even without evidence of afib or flutter during the current hospitalization. Even in patients who have undergone catheter ablation therapy there is uncertainty as to what the risk of recurrence of AF is over the long term, AF can recur without symptoms and be unrecognized by the patient or physician. Therefore anticoagulation is still indicated stroke patients with catheter ablation therapy for AF.

        • Yes: Anticoagulation therapy was prescribed at discharge.
        • No/ND: Anticoagulation therapy was not prescribed at discharge or unable to determine from medical record documentation.
        • NC: There is documentation of a reason for not prescribing anticoagulation therapy at hospital discharge
        Notes for Abstraction:
        • See Table 5 for a list of medications used for anticoagulation therapy :
        • Select "No/ND" for patients who are discharged only on low doses (5000 units subQ bid) of heparin or equivalent doses for DVT prophylaxis using LMWH
        • Select “No/ND” for patients who are discharged only on antiplatelet therapy, without anticoagulation therapy
        • In determining whether anticoagulation therapy was prescribed at discharge, it is not uncommon to see conflicting documentation amongst different medical record sources. For example, the discharge summary may list an anticoagulant that is not included in any of the other discharge medication sources (e.g., discharge orders). All discharge medication documentation available in the chart should be reviewed and taken into account by the abstractor.
          • In cases where there is an anticoagulant in one source that is not mentioned in other sources, it should be interpreted as a discharge medication (select "Yes") unless documentation elsewhere in the medical record suggests that it was NOT prescribed at discharge - Consider it a discharge medication in the absence of contradictory documentation.
          • If documentation is contradictory (e.g., physician noted “d/c Coumadin” in the discharge orders, but Coumadin is listed in the discharge summary’s discharge medication list), or after careful examination of circumstances, context, timing, etc., documentation raises enough questions, the case should be deemed "unable to determine" (select "No").
          • Consider documentation of a hold on an anticoagulant after discharge in one location and a listing of that anticoagulant as a discharge medication in another location as contradictory ONLY if the timeframe on the hold is not defined (e.g., “Hold Coumadin”). Examples of a hold with a defined timeframe include “Hold Coumadin x2 days” and “Hold warfarin until after stress test.”
          • If an anticoagulant is NOT listed as a discharge medication, and there is only documentation of a hold or plan to delay initiation/restarting of anticoagulation therapy after discharge (e.g., “Hold Coumadin x2 days,” “Start Coumadin as outpatient,” “Hold Coumadin”), select “No”.
          • If two discharge summaries are included in the medical record, use the one with the latest date/time. If one or both are not dated or timed, and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Use the dictated date/time over transcribed date/time, file date/time, etc.
            Examples:
          • − Two discharge summaries, one dictated 5/22 (day of discharge) and one dictated 5/27 - Use the 5/27 discharge summary.
            − Two discharge medication reconciliation forms, one not dated and one dated 4/24 (day of discharge) - Use both.
        • Disregard an anticoagulant medication documented only as a recommended medication for discharge (e.g., “Recommend sending patient home on dabigatran”). Documentation must be clearer that an anticoagulant was actually prescribed at discharge.
        • Disregard documentation of anticoagulant prescribed at discharge when noted only by medication class (e.g., “Anticoagulant Prescribed at Discharge: Yes” on a core measures form). The anticoagulant must be listed by name.
        • Reasons for not prescribing anticoagulation therapy must be documented by a physician, advance practice nurse or physician assistant.
        • If reasons are not mentioned in the context of anticoagulation therapy, do not make inferences (e.g., do not assume that anticoagulation therapy was not prescribed because of a bleeding disorder unless documentation explicitly states so).
          • Reasons must be explicitly documented (e.g., “Active GI bleed – anticoagulation therapy contraindicated”, “No warfarin” [no reason given].).
          • Physician/APN/PA or pharmacist documentation of a hold on an anticoagulant medication or discontinuation of an anticoagulant medication that occurs during the hospital stay constitutes a “clearly implied” reason for not prescribing anticoagulation therapy at discharge. A hold/discontinuation of all p.o. medications counts if an oral anticoagulant medication (e.g., warfarin) was on order at the time of the notation.
            EXCEPTIONS:
              • Documentation of a conditional hold or discontinuation of an anticoagulant medication (e.g., “Hold Coumadin if guaiac positive”, “Stop warfarin if rash persists”, “No warfarin for 24 hours post thrombolytic therapy”).
              • Discontinuation of a particular anticoagulant medication documented in combination with the start of a different anticoagulant medication (i.e., switch type of anticoagulant medication) does not count as a reason for not prescribing an anticoagulant medication at discharge. Examples:
                  - “Stop warfarin” and “Start warfarin 2 mg po daily” in same physician order
                  - “Change Coumadin to Pradaxa” in progress note
                  - Do not continue after discharge” checked for warfarin and “Continue after discharge” checked for Coumadin on a physician-signed discharge medication reconciliation form
              • Discontinuation of an anticoagulant medication at a particular dose documented in combination with the start of a different dose of that anticoagulant (i.e., change in dosage) does not count as a reason for not prescribing an anticoagulant medication at discharge.
                Examples:
                  - “Stop warfarin 5 mg po daily” and “Start warfarin 2.5 mg po daily” in same physician order
                  - “Decrease dabigatran 150 mg po BID to 75 mg po BID” in progress note
                  - Do not continue after discharge” checked for Coumadin 5 mg and “Continue after discharge” check for Coumadin 2.5 mg on a physician-signed discharge medication reconciliation form
        • Deferral of anticoagulation therapy from one physician/APN/PA or pharmacist to another does NOT count as a reason for not prescribing anticoagulation therapy at discharge unless the problem underlying the deferral is also noted. Examples:
              • “Consulting neurologist to evaluate pt. for warfarin therapy.” - select “No”.
              • “Rule out GI bleed. Start Coumadin if OK with neurology.” - select "Yes”.
        • If there is documentation of a plan to initiate/restart anticoagulation therapy, and the reason/problem underlying the delay in starting/restarting anticoagulation therapy is also noted, this constitutes a “clearly implied” reason for not prescribing anticoagulation therapy at discharge.
          Acceptable examples (select “Yes”):
              • “Stool Occult Blood positive. May start Coumadin as outpatient.”
              • “Start warfarin if hematuria subsides.”
        • Unacceptable examples (select “No”):
              • “Consider starting Coumadin in a.m.”
              • “May add warfarin when pt. can tolerate
        • Reasons do NOT need to be documented at discharge or otherwise linked to the discharge timeframe: Documentation of reasons anytime during the hospital stay are acceptable (e.g., mid-hospitalization note stating “no warfarin due to rectal bleeding” - select “Yes,” even if documentation indicates that the rectal bleeding has resolved by the time of discharge and warfarin was restarted).
        • Crossing out of an anticoagulant medication counts as a "clearly implied reason" for not prescribing anticoagulation therapy at discharge only if on a pre-printed form.
        • An allergy or adverse reaction to one type of anticoagulant would NOT be a reason for not administering all anticoagulants. Another medication can be ordered.
        • When the current record includes documentation of a pre-arrival reason for no anticoagulation therapy, the following counts regardless of whether this documentation is included in a pre-arrival record made part of the current record or whether it is noted by hospital staff during the current hospital stay:
          • Pre-arrival hold/discontinuation or notation such as "No Coumadin" IF the underlying reason/problem is also noted (e.g., “Coumadin held in transferring hospital due to possible GI bleed”)
          • Pre-arrival "other reason" (other than hold/discontinuation or notation of "No warfarin") (e.g., "Hx GI bleeding with warfarin" in transferring ED record).
        • Reasons for not PRESCRIBING anticoagulation therapy at hospital discharge:
          • Allergy to all anticoagulant medications
          • Aortic dissection
          • Bleeding disorder
          • Brain/CNS cancer
          • CVA, hemorrhagic
          • Extensive/metastatic CA
          • Hemorrhage, any type
          • Intracranial surgery/biopsy
          • Patient/family refusal
          • Peptic ulcer
          • Planned surgery within 7 days following discharge
          • Risk of bleeding
          • Unrepaired intracranial aneurysm
          • Other documented by physician/APN/PA or pharmacist

        Hospitalization Data, Discharge Data

        Summary of Changes

        OPTIONAL: If NC, documented reasons for no anticoagulation (Select all that apply)

        Select the specific reason(s) documented for not prescribing anticoagulation therapy at discharge for patients with atrial fibrillation/flutter.

        • Allergy to or complication r/t warfarin or heparins (hx or current)
        • Mental status
        • Patient refused
        • Risk for bleeding or discontinued due to bleeding
        • Risk for falls
        • Serious side effect to medication
        • Terminal illness/Comfort Measures Only

        Notes for Abstraction:

        • Reasons for not prescribing anticoagulation therapy must be documented by a physician, advance practice nurse or physician assistant.
        • If reasons are not mentioned in the context of anticoagulation, do not make inferences (e.g., do not assume that anticoagulation therapy is not being prescribed because of a bleeding disorder unless documentation explicitly states so.)
        • It is not intended that this list of reasons is inclusive of all possible reasons for not prescribing anticoagulation therapy at discharge. Select if any of these were documented as reasons for not prescribing antithrombotic therapy at discharged.

        Hospitalization Data, Discharge Data

        Summary of Changes

        OPTIONAL: Antihypertensive Tx

        Determine if antihypertensive treatment was prescribed at discharge. The appropriate time to initiate antihypertensive medication in the setting of acute ischemic stroke is unknown. However, many patients are discharged on antihypertensive medications. Record all agents based on class of action. For combination agents, record both classes. Select the class of medication regardless of the indication for this medication. Medications in these classes may be used to treat alternate conditions beyond hypertension. A list of anti-hypertensive medications can be found in Table 1.

        • None prescribed/ND
        • None - contraindicated
        • ACE Inhibitors
        • ARB
        • Beta Blockers
        • Ca++ Channel Blockers
        • Diuretics
        • Other anti-hypertensive med

        Examples:

        • Patient 350a is admitted to the in-patient unit with right hemiparesis and dysarthria. His pre-admission medications were lisinopril, aspirin, metformin and furosemide. His metformin is held but all other medications are continued. Paroxysmal atrial fibrillation (PAF) is noted during admission but he returns to sinus rhythm spontaneously. He is discharged on day 5 on his original pre-admission medications and the DASH diet. Data Entry will be to multi-select "ACE Inhibitors" and "Diuretics".
        • The notes for Patient 350b document critical intracranial stenosis. At discharge his blood pressure is 100/60 and his lisinopril and furosemide were held with a plan to restart if BP increases. Data entry would be to select "None - contraindicated".

        Hospitalization Data, Discharge Data

        REQUIRED: Cholesterol-Reducing Tx (Select all that apply)

        Enter the cholesterol reducing medication the patient has been prescribed upon discharge.

        • None prescribed/ND: Cholesterol reducing treatment was not prescribed at discharge or unable to determine from medical record documentation
        • None contraindicated: There is documentation of a reason for not prescribing cholesterol reducing treatment at discharge
        • Statin: See Table 2 for a list statin containing medications
        • Fibrate: See Table 2 for a list of fibrate medications
        • Niacin: See Table 2 for a list of niacin containing medications
        • Absorption Inhibitor: See Table 2 for a list of absorption inhibitor containing medications
        • PCSK9 Inhibitor: See Table 2 for a list of PCSK Inhibitor containing medications
        • Other med: See Table 2 for a list of other medications

        Notes for Abstraction:

        • In determining whether cholesterol reducing therapy was prescribed at discharge, it is not uncommon to see conflicting documentation among different medical record sources. For example, the discharge summary may list a drug that is not included in any of the other discharge medication sources (e.g., discharge orders). All discharge medication documentation available in the medical record should be reviewed and taken into account by the abstractor.
          • In cases where there is a cholesterol reducing drug noted in one source that is not mentioned in other sources, it should be interpreted as a discharge medication (select the specified class of cholesterol reducer) unless documentation elsewhere in the medical records suggest that it was NOT prescribed at discharge – Consider it a discharge medication in the absence of contradictory documentation.
          • If documentation is contradictory (e.g., MD noted discontinuation of the cholesterol reducing therapy in the discharge medication orders, but it is listed in the discharge summary’s discharge medication list), or after careful examination of circumstances, context, timing, etc., documentation raises enough questions, the case should be deemed “unable to determine” (select “None prescribed/ND”).
          • When there is a documented plan to delay initiation/restarting of a cholesterol reducing therapy for a time period after discharge, select “None prescribed/ND”.
        • For combination agents, select both medication classes. (e.g. Patient is prescribed Vytorin, select “Statin” AND “Absorption inhibitor”
        • Reasons for not prescribing cholesterol reducing medication must be documented by a physician, advance practice nurse or physician assistant
        • If reasons are not mentioned in the context of cholesterol reducing treatment, do not make inferences (e.g., do not assume that cholesterol reducing medication is not being prescribed because of a history of ICH unless documentation explicitly states so.)
        • Documented reasons for not prescribing cholesterol reducing treatment may include (list is not all-inclusive):
          • Allergy to or complication related to cholesterol reducing treatment
            • Documentation of an allergy/sensitivity to one particular statin medication is acceptable to take as an allergy to the entire class of statin medications (e.g., “Allergic to Lipitor”).
            • An allergy or adverse reaction to one class of cholesterol reducing medications would NOT be a reason for not administering all cholesterol reducing medications. Another medication class can be ordered. (e.g. If patient is allergic to statins, a fibrate could be prescribed).
          • Patient/family refusal
          • Terminal illness/Comfort Measures Only
          • Hepatitis
          • Hepatic failure
          • Myalgias
          • Rhabdomyolysis
          • ICH within prior 6 months

        Example: Patient 360a is admitted to the in-patient unit with right hemiparesis and dysarthria. His pre-admission medications were lisinopril, aspirin, metformin and furosemide. His metformin is held but all other medications are continued. LDL is noted to be 180 and he has a recent non-q wave MI. He is discharged on day 5 on his original pre-admission medications and pravastatin plus a low-cholesterol diet. Data entry will be to select "Statin".

        Hospitalization Data, Discharge Data

        Summary of Changes

        REQUIRED: Statin Medication and Dose (Specify)

        Select from the list the specific statin containing medication and the total daily dosage that was prescribed at discharge.

        Notes for Abstraction:

        • Statin medications are routinely prescribed to be taken once daily. If the patient is prescribed a statin dose to be taken more than once daily, add the individual doses and enter as “Total Daily Dosage.”
        • If the patient is prescribed Atorvastatin(Lipitor) at a total daily dose of 40 mg or greater, select “ >= 40 mg”. 40 mg is the minimum daily dosage which qualifies as intensive statin therapy. For all other dosages, select the specific total daily dose prescribed.
        • If the patient is prescribed Rosuvastatin (Crestor) at a total daily dose of 20 mg or greater, select >= 20 mg. 20 mg is the minimum daily dosage which qualifies as intensive statin therapy. For all other dosages, select the specific total daily dose prescribed.
        • Fluvastatin XL is only available in dose, 80mg daily and there is NOT an unknown option for that medication dose. In the absence of a documented daily dose for fluvastatin, you may select 80mg. This exception is only for Fluvastatin XL due to the availability of one dosing option and DOES NOT extend to other statin medications.
        • Medications may contain both a statin along with another medication, such as Niacin. Where these medications may meet the guideline directed dose for statins, they will quality for inclusion in the Intensive Statin Therapy numerator.
        • Statin therapy with intensive lipid-lowering effects may be defined as those statin agents and doses which have been demonstrated to produce a mean LDL reduction of approximately 50% or greater.
        • You will be required to document a reason for non-treatment if the statin daily dose does not meet the guideline recommended dose. Patients 75 years or younger should receive a high intensity statin dose unless contraindicated. Patients greater than 75 years should receive a moderate or high dose. Please refer to table 6 for classifications of low, moderate and high dose statins.
        • If the statin daily dose prescribed is not documented or is not among those listed in the dose dropdown, select "Unknown"

        *Additional information can be found in the 2018 AHA/ACC/AACVPR/AAPA/ABC/-ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol
        https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625

        Hospitalization Data, Discharge Data

        Summary of Changes

        REQUIRED: Documented Reason for Not Prescribing Guideline Recommended Dose?

        Specify the reasons for not prescribing the appropriate guideline recommended dose:

        • Intolerant to moderate or greater intensity
        • No evidence of atherosclerosis (cerebral, coronary or peripheral vascular disease)
        • Other documented reason
        • Unknown/ND

        Notes for Abstraction:

        • Reasons for not prescribing guideline recommended dose for statin therapy at discharge must be documented by a physician, PA, or APN.
        • Reasons for not prescribing guideline recommended dose must be mentioned in the context of statin therapy intensity, do not make inferences. (e.g. Do not assume that more intense statin therapy is not being prescribed because a patient has muscle pain and weakness. Documentation must mink muscle pain or weakness to a reason for not prescribing a higher dose of statin therapy.)
        • Select "Intolerant to moderate or greater intensity" if there is documentation in the medical record that the reason for not prescribing guideline recommended dose is that the patient was intolerant to a higher intensity statin than prescribed.
          • Acceptable examples include: "patient intolerant to greater intensity statin, maintain current dose", "muscle pain in past, trial of low dose statin", "chronic kidney disease - proceed with 10mg Simvastatin"; "liver disease so intolerant to higher dose".
        • Select "No evidence of atherosclerosis (cerebral, coronary or peripheral vascular disease)", if there is documentation that the patient's stroke is not of atherosclerotic origin AND there is no other history or evidence that the patient has atherosclerosis.
        • "Other documented reasons" may include patient/family refusal to increase statin dose.
        • Select "Unknown/ND" if the reason for not prescribing a guideline recommended dose is not documented in the medical record.

        Examples:

        • Patient was admitted with cardio embolic ischemic stroke and no other vascular risk factors. The patient has elevated cholesterol with LDL measurement of 115 mg/dL and is discharged on atorvastatin 20 mg. The physician documents that the patient is not a candidate for intensive statin therapy due to no atherosclerosis. Select "No evidence of atherosclerosis".

        Hospitalization Data, Discharge Data

        Summary of Changes

        Documented Reason for Not Prescribing a Statin Medication at Discharge

        Collected For: STK-6

        Definition: Reasons for not prescribing a statin medication at discharge:

        • Statin medication allergy
        • LDL-c less than 70 mg/dL
        • Other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist

        Statins are a class of pharmaceutical agents that modify LDL cholesterol by blocking the action of an enzyme in the liver which is needed to synthesize cholesterol thereby decreasing the level of cholesterol circulating in the blood.

        Question: Is there documentation of a reason for not prescribing a statin medication at discharge?

        Format: Single Select

        Allowable Values:

        • Yes
        • No

        Notes for Abstraction:

        • Yes - There is documentation of a reason for not prescribing a statin medication at discharge.
        • No - There is no documentation of a reason for not prescribing a statin medication at discharge, OR unable to determine from the medical record documentation.
        • A statin medication "allergy" or "sensitivity" documented at anytime during the hospital stay counts as an allergy regardless of what type of reaction might be noted (e.g., "Allergies: Atorvastatin - Nausea" - select "Yes.").
        • Documentation of an allergy/sensitivity to one particular statin medication is acceptable to take as an allergy to the entire class of statin medications (e.g., "Allergic to Lipitor").
        • Documentation of a LDL-c less than 70 mg/dL anytime during the hospital stay is an acceptable stand-alone reason for not prescribing statin medication at discharge – Linkage with statin is not needed. If more than one LDL value is documented, the highest value must be less than 70 mg/dL. Direct or calculated fasting or non-fasting values are both acceptable. LDL values obtained within 30 days prior to hospital arrival are acceptable to select “Yes.”
        • When conflicting information is documented in a medical record, select "Yes".
        • Reasons for not administering statin therapy must be documented by a physician/APN/PA or pharmacist with one exception: Patient/family refusal of any form of statin therapy (e.g., “Lipitor refused,” “Patient refusing statin therapy”) may be documented by a nurse.
        • In determining whether there is a reason documented by physician/APN/PA or pharmacist for not prescribing a statin medication at discharge:
          • Reasons must be explicitly documented (e.g., "Chronic liver failure - Statins contraindicated", "Hx muscle soreness with statins in past") or clearly implied (e.g., "No evidence of atherosclerosis - no statin therapy", "Pt. refusing all medications," "Supportive care only - no medication," statin medication on pre-printed order form is crossed out, "Statins not indicated," "No statin medications" [no reason given]). If reasons are not mentioned in the context of statin medications, do not make inferences (e.g., do not assume that a statin medication is not being prescribed because of the patient's history of alcoholism or severe liver disease alone).
          • Documentation of "do not continue" or "do not convert" a home statin medication to an inpatient medication,or an inpatient statin medication to a discharge medication, does not count as a reason for not prescribing statin medication at discharge. Do not infer that a statin medication was not prescribed or discontinued without explicit documentation of a reason for not prescribing a statin medication at discharge. Example:
            • Patient on Atorvastin 80 mg while an inpatient. During discharge medication reconcilliation, physician checks "do not convert" box next to atorvastin, select "No."
          • Reason documentation which refers to a more general medication class is not acceptable (e.g., "No cholesterol-reducers," "Hold all lipid-lowering medications").
          • Deferral of statin medication from one physician/APN/PA or pharmacist to another does NOT count as a reason for not prescribing a statin medication unless the problem underlying the deferral is also noted. Examples:
            • "Consulting neurologist to evaluate pt. for statin therapy" - select "No."
            • "Severe diarrhea. Start statin if OK with neurology." - select "Yes."
          • If there is documentation of a plan to initiate/restart a statin medication, and the reason/problem underlying the delay in starting/restarting the medication is also noted, this constitutes a "clearly implied" reason for not prescribing a statin medication at discharge.
          • Acceptable examples (select "Yes"):
            • "Liver enzymes high. May start lovastatin as outpatient."
            • "Add statin if myalgias resolve"
          • Unacceptable examples (select "No"):
            • "Consider starting statins in a.m"
            • "May add Zocor when pt. can tolerate."
          • Reasons do NOT need to be documented at discharge or otherwise linked to the discharge timeframe: Documentation of reasons anytime during the hospital stay are acceptable (e.g., mid-hospitalization note stating "no statin medications due to abnormal liver enzymes" - select "Yes," even if documentation indicates that the liver enzyme levels normalized by the time of discharge and the lipid-lowering medication was restarted).
          • Statin medications may also be referred to as HMG CoA reductase inhibitors
          • When the current record includes documentation of a pre-arrival reason for no statin medication, the following counts regardless of whether this documentation is included in a pre-arrival record made part of the current record or whether it is noted by hospital staff during the current hospital stay. Examples:
            • "Pre-arrival statin allergy"
            • "Hx muscle soreness to statins in past" documented in a transferring record.

        Suggested Data Sources:

        • Consultation Notes
        • Emergency Department Record
        • History and Physical
        • Progress Notes
        • Physician Orders
        • Discharge Summary
        • Medication Administration Record (MAR)
        • After Visit Summary (AVS)
        • Medication Reconciliation Form
        • Excluded Date Sources: Any documentation dated/ timed after discharge, except discharge summary.

        Additional Notes / Guidelines for Abstraction:

        • Inclusion:
          • None
          • Refer to Appendix C, Table 8.1 for a comprehensive list of Statin Medications

        Element definition from Manual for National Hospital Inpatient Quality Measures

        Reasons for not prescribing a statin medication at discharge:

        Statins are a class of pharmaceutical agents that modify LDL cholesterol by blocking the action of an enzyme in the liver which is needed to synthesize cholesterol thereby decreasing the level of cholesterol circulating in the blood.

        Yes (There is documentation of a reason for not prescribing a statin medication at discharge.)

        No ( There is no documentation of a reason for not prescribing a statin medication at discharge, OR unable to determine from medical record documentation.)

        Notes for Abstraction:

        • A statin medication "allergy" or "sensitivity" documented at anytime during the hospital stay counts as an allergy regardless of what t