Get with the Guidelines® - Stroke PMT®
Abstraction Guidelines Updated August 2022
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
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.
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 |
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:
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:
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:
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:
- Ischemic stroke
- Transient ischemic attack
- Subarachnoid hemorrhage
- Intracerebral hemorrhage
- Stroke not otherwise specified
- No stroke related diagnosis
- Elective Carotid Intervention only
Refer to Entry Criteria for a list of the diagnosis codes used to describe these diagnoses.
Notes for Abstraction:
- For most cases the Final Clinical diagnosis related to stroke will be equivalent to the principal diagnosis code. However, for some cases such as in-patient or in-hospital stroke or TIA the principal diagnosis code and the Final diagnosis related to stroke will differ. The Final diagnosis related to stroke can be the principal or secondary diagnosis assigned at discharge. Refer to the definition of principal diagnosis below for additional information.
- For patients whose symptoms resolve upon arrival to ED, but then return later during the hospitalization (symptoms > 24hrs or infarction on brain imaging while an inpatient) select ‘ischemic stroke’. For the element Patient location when stroke symptoms discovered select ‘stroke occurred after hospital arrival (in ED/Obs/inpatient)’.
- For patients who arrive with symptoms of stroke and have complete resolution after IV alteplase select ‘ischemic stroke’. These cases are sometimes referred to as "aborted stroke".
- For patients admitted with ischemic stroke who are treated with IV alteplase or other medications and develop the complication of intracerebral hemorrhage select ‘ischemic stroke’. If a patient is transferred to your hospital for management of a hemorrhagic complication after treatment with IV alteplase for an ischemic stroke at the referring hospital select ‘ischemic stroke’ as this is the stroke diagnosis that initially lead to the patient’s hospitalization.
- For patients admitted for non-stroke related illness, but who experience a stroke after admission select the stroke diagnosis documented by the physician. These in-patient/in-hospital stroke cases are optional for the Get With the Guidelines registry; they are included in the Get With the Guidelines Inpatient Stroke measures, but excluded from Get With the Guidelines Achievement measures. For the element Patient location when stroke symptoms discovered select ‘stroke occurred after hospital arrival (in ED/Obs/inpatient)’.
- Patients who present with neurological symptoms, but after work-up are determined not to have suffered from a stroke or TIA, are not required to be entered into the PMT. Select ‘no stroke related diagnosis’ when:
- The patient presents with stroke mimic or a stroke-like clinical picture and IV alteplase is initiated, but the final clinical diagnosis is later determined not to be stroke related. You can report the stroke mimic or stroke-line diagnosis (e.g., migraine, seizure) in the subsequent data element “If No Stroke Related Diagnosis”. This allows hospitals to track outcomes of the relatively small number of patients who appeared to be having a stroke and were treated with IV alteplase, but later turned out to have a stroke mimic.
- The patient presents with stroke mimic or a stroke-like clinical presentation and a ‘stroke code’ is activated and/or the patient is followed by the stroke service until the stroke diagnosis is ruled out. Also complete the subsequent data element “If No Stroke Related Diagnosis”.
- Patients who are found to have incidentally discovered infarcts (silent, subclinical, or prior CNS infarction) are not required to be entered into the tool.
- For patients who are documented as having "CVA" or "Stroke" in their medical record, without any additional documentation regarding the stroke type and who have no evidence of hemorrhage on initial brain imaging select ‘ischemic stroke’.
- For patients whom there is evidence of both ischemic injury and brain hemorrhage on initial imaging select "stroke not otherwise specified."
- Patients who present with symptoms that are not recognized as having been caused by stroke while in the initial phase of their hospital care, but are determined ultimately to have had a stroke or TIA select the stroke or TIA diagnosis documented by the physician.
- Select “Elective Carotid Intervention only” for patients with documentation that demonstrates that the current admission is solely for the performance of an elective carotid intervention (e.g., elective carotid endarterectomy, angioplasty, carotid stenting). This option has been added for sites that are entering patients admitted for the performance of an elective carotid intervention because the patient falls into their TJC/CM sampling plan. If this diagnosis is selected, only those data elements required by TJC for this patient population will be required to save the form as complete. Do not select this option for patients that present with an acute stroke event.
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
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.
- Migraine: Includes physician documentation that the neurological symptoms mimicking stroke were caused by migraine (migraine headache, classic or common migraine, migraine with or without aura, status migrainosus) that could include discharges with an ICD-9-CM diagnosis code of 346.0-346.93.
- Seizure: Includes physician documentation that the neurological symptoms mimicking stroke were caused by seizure or convulsion that could include discharges with an ICD-9-CM diagnosis code of 345: Epilepsy, 780.3: Convulsions, 780.33: Post traumatic seizures, 780.39: Other convulsions.
- Delirium: Includes physician documentation that the neurological symptoms mimicking stroke were caused by delirium attributed to any cause (e.g. alcohol or sedative drug withdrawal, drug abuse, electrolyte or other body chemical disturbances, infections etc.)
- Electrolyte or metabolic imbalance: Includes physician documentation that the neurological symptoms mimicking stroke were caused by hyponatremia, hypercalcemia, hypothyroidism or other electrolyte or metabolic disturbance.
- Functional disorder: Includes physician documentation that neurological symptoms were the result of a conversion or functional disorder that could include discharges with an ICD-9-CM diagnosis code of 300.11: Conversion Disorder. Functional Disorder and conversion disorder are terms that may be used interchangeably. A conversion disorder is a condition in which patients present with neurological symptoms such as numbness, blindness, or paralysis without a neurological cause.
- Other: Final clinical diagnosis is determined not to be stroke related, but the specific diagnosis is something other than those provided. This could include ICD-9 codes such as 780.4; Dizziness and giddiness, 784.3; Aphasia; 784.5; Other speech disturbance; 784.51; Dysarthria, 787.2; Dysphagia780.97; Altered mental status 386.1 and 386.10: Peripheral vertigo (this list is not all inclusive).
- Uncertain: Final clinical diagnosis is determined not to be stroke related but the cause of the patient’s symptoms is not confirmed or unknown at the time of discharge.
Notes for abstraction:
- This data element can be used to capture the final diagnosis for those patients in whom stroke was initially suspected but after complete clinical work-up were determined not to have had a stroke. You can choose to enter patients with no stroke related diagnosis if:
- The patient presents with stroke mimic or a stroke-like clinical picture and IV tPA is initiated, but after neuroimaging studies and further work-up the final clinical diagnosis is later determined not to be stroke related.
- The patient presents with stroke mimic or a stroke-like clinical presentation and a stroke code is activated and/or the patient is followed by the stroke service until the stroke diagnosis is ruled out.
- This assignment of diagnosis should be done independently of the ICD-9-CM code assigned. However, the diagnosis selected here should ideally be equivalent to the final ICD-9-CM code. In circumstances when another ICD-9-CM code has been chosen and there is a discrepancy, please consult your local Stroke Champion or Stroke Team lead and/or the hospital administrator responsible for assigning ICD-9 codes.
- These patients will be excluded from all Get With The Guidelines measures
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:
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:
- Only accept terms identified in the list of inclusions. No other terminology will be accepted.
- Physician/APN/PA documentation of comfort measures only (hospice, comfort care, etc.) mentioned in the following contexts suffices:
- Comfort measures only recommendation
- Order for consultation or evaluation by a hospice care service
- Patient or family request for comfort measures only
- Plan for comfort measures only
- Referral to hospice care service
- Determine the earliest day the physician/APN/PA DOCUMENTED comfort measures only in the ONLY ACCEPTABLE SOURCES. Do not factor in when comfort measures only was actually instituted
- Examples
- "Discussed comfort care with family on arrival" noted in day 2 progress note - Select "Day 2 of After."
- POLST order for comfort care dated prior to arrival - Select "Day 0 or 1."
- If any of the inclusions are documented in the ONLY ACCEPTABLE SOURCES, select "1," "2," or "3" accordingly, unless otherwise specified in this data element.
- Consider comfort measures only documentation in the discharge summary as documentation on the last day of the hospitalization, regardless of when the summary is dictated.
- Documentation of an Inclusion term in the following situations should be disregarded. Continue to review the remainder of the ONLY ACCEPTABLE SOURCES for acceptable Inclusion terms. If the ONLY documentation found is an Inclusion term in the following situations, select “not documented/UTD”:
- Documentation that is dated prior to arrival or documentation which refers to the pre-arrival time period (e.g., comfort measures only order in previous hospitalization record, "Pt. on hospice at home" in MD ED note).
- EXCEPTION: State-authorized portable orders (SAPOs). SAPOs are specialized forms, Out-of-Hospital DNR (OOH DNR) or Do Not Attempt Resuscitation (DNAR) orders, or identifiers authorized by state law, that translate a patient's preferences about specific-end-of-life treatment decisions into portable medical orders. Examples:
DNR-Comfort Care form
MOLST (Medical Orders for Life-Sustaining Treatment)
POLST (Physician Orders for Life-Sustaining Treatment)
Pre-printed order forms signed by the physician/APN/PA:
Disregard an Inclusion term in a statement that is not part of the order or that is not clearly selected (on a form that offers options to select from).
Examples:
Inclusion term used only in the title of the form (e.g., "DNR-Comfort Care" form, option "Comfort Care" is not checked)
Inclusion term used only in the pre-printed instruction for completing the form (e.g. "Copy of form to hospice", "Instructions" section of the form further defines the option "Comfort Care")
If there is a specific option for “Comfort Measures Only” (or other Inclusion term) that is unchecked, then disregard documentation on that form, regardless of whether that Inclusion term might be used in a different option that is checked.
Example: POLST form - The "Limited Additional Interventions" option checked is described as "In addition to care described in Comfort Measures Only, use medical treatment, antibiotics, ..."- Inclusion term clearly described as negative.
Examples:
- "No comfort care"
- "Not a hospice candidate"
- "Not appropriate for hospice care"
- "I offered hospice care consult to discuss end of life issues. Family did not show any interest."
- "Patient declines hospice care at this time but I feel this will be an important plan of care when his condition deteriorates further"
- "Comfort care would also be reasonable - defer decision for now"
- Comfort measures made conditional upon whether or not the patient arrests. Examples:
- DNRCCA" (Do Not Resuscitate - Comfort Care Arrest)
- Comfort Care Protocol will be implemented in the event of a cardiac arrest or a respiratory arrest"
- Family requests comfort measures only should the patient arrest"
- Documentation of "CMO" should be disregarded if documentation makes clear it is not being used as an acronym for Comfort Measures Only (e.g., "hx dilated CMO" - Cardiomyopathy context).
If there is documentation of an Inclusion term clearly described as negative in one source and an Inclusion term NOT described as negative in another source, that second source would still count for comfort measures only.
Examples:
On Day 0 the physician documents “The patient is not a hospice candidate.” On Day 3, the physician orders a hospice consult. Select “2”.
On Day 1 the physician documents the patient is comfort measures only. On Day 2 the physician documents “The patient is refusing CMO.” Select “1”.- For inpatient strokes, assess earliest documentation of comfort measures only from date/time of discovery of stroke symptoms. If comfort measures was instituted prior to the date/time of discovery of stroke symptoms, select "Day 1 or 2".
- Example: Patient 070 arrived to the hospital on 4/1/2012 and was admitted the same day for acute MI. On 4/3/2012 the nurse finds the patient unable to speak and unable to move his right side. The stroke team is consulted and it is determine that the patient had an ischemic stroke. The neurologist orders a consultation for hospice care services on 4/4/2012. Select "Day 1 or 2" as the day of discovery of stroke symptoms (4/3/2012) is day 1 for inpatient strokes.
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.
- MM = Month (01-12)
- DD = Day (01-31)
- YYYY = Year (20XX)
- HH = Hour (00-23)
- MM = Minutes (00-59)
- UTD = Unable to Determine
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
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 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):
- If the date/time of arrival is unable to be determined from medical record documentation, 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
- The medical record must be abstracted as documented (taken at "face value"). When the date/time documented is obviously in error (not a valid format/range or outside of the parameters of care [after the Discharge Date ]) and no other documentation is found that provides this information, the abstractor should select "UTD."
- Examples Date:
- Documentation indicates the Arrival Date was 03- 42 -20XX . No other documentation in the list of Only Acceptable Sources provides a valid date. Since the Arrival 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 all documentation within the Only Acceptable Sources indicates the Arrival Date was 03-12-20XX. Other documentation in the medical record supports the date of death as being accurate. Since the Arrival Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select "UTD."
- Examples Time:
- Documentation indicates the Arrival Time was 3300. No other documentation in the list of Only Acceptable Sources provides a valid time. Since the Arrival Time is outside of the range 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 date as described above will be rejected from the Joint Commission's Data Warehouse. Use of "UTD" for Arrival Date/Time allows the case to be accepted into the warehouse.
- Review the Only Acceptable Sources to determine the earliest date/time the patient arrived at the ED, nursing floor, or observation, or as a direct admit to the cath lab. The intent is to utilize any documentation which reflects processes that occurred in the ED or after arrival to the nursing floor/observation/cath lab for a direct admit.
- Documentation outside of the Only Acceptable Sources list should NOT be referenced (e.g., ambulance record, physician office record, H&P).
Examples:
- ED Triage Date/Time 03-22-20xx 2355. ED rhythm strip dated/timed 03-23-20xx 0030. EMS report indicates patient was receiving EMS care from 0005 through 0025 on 03-23-20xx. The EMS report is disregarded. Enter 03-22-20xx for Arrival Date.
- ED noted arrival time of 0100 on 04-14-20xx. Lab report shows blood culture collected at 2345 on 04-13-20xx. It is not clear that the blood culture was collected in the ED because the lab report does not specify it was collected in the ED (unable to confirm lab report as an Only Acceptable Source). Enter 04-14-20xx for Arrival Date.
- ED Triage Date/Time 06-18-20xx 0025. EMS report indicates patient arrived by ambulance on 06-17-20xx 2355. Patient routed directly to CT. The EMS report is disregarded. Enter 06-18-20xx for Arrival Date.
- ED Triage Time 0800. ED rhythm strip 0830. EMS report indicates patient was receiving EMS care from 0805 through 0825. The EMS report is disregarded. Enter 0800 for Arrival Time.
- ED noted arrival time of 0945. Lab report shows blood culture collected at 0830. It is not clear that the blood culture was collected in the ED because the lab report does not specify it was collected in the ED (unable to confirm lab report as an Only Acceptable Source). Enter 0945 for Arrival Time.
- ED Triage Time 1525. EMS report indicates patient was receiving care 1435 through 1455. ED report documents time of head CT 1505. The EMS report is disregarded. Enter 1505 for Arrival Time.
• Arrival date.time should NOT be abstracted simply as the earliest date in one of the Only Acceptable Sources, without regard to other substantiating documentation. When looking at the Only Acceptable Sources, if the earliest date documented appears to be an obvious error, this date should not be abstracted.
Examples:
- ED arrival time noted as 0030 on 10-29-20xx. ED MAR shows an antibiotic administration time of 0100 on 10-28-20xx. Surrounding documentation on the ED MAR makes clear that the 10-28-20xx date is an obvious error - Date was not changed to 10-29-20xx. The antibiotic administration date/time would be converted to 0100 on 10-29-20xx. Enter 10-29-20xx for Arrival Date.
- ED MAR shows an antibiotic administration time of 1430 on 11-03-20xx. All other dates in the ED record note 12-03-20xx. The antibiotic administration date of 11-03-20xx would not be used for Arrival Date because it is an obvious error.
- ED ECG dated/timed as 05-07-20xx 2142. ED Greet Date/Time 05-08-20xx 0125. ED Triage Date/Time 05-08-20xx 0130. There is no documentation in the Only Acceptable Sources which suggests the 05-07-20xx is an obvious error. Enter 05-07-20xx for Arrival Date.
- ED RN documents on a nursing triage note dated 04-24-20xx, “Blood culture collected at 2230.” ED arrival time is documented as 0130 on 04-25-20xx. There is no documentation in the Only Acceptable Sources which suggests the 04-24-20xx is an obvious error. Enter 04-24-20xx for Arrival Date.
- ED arrival time noted as 2300 on 10-28-20xx. ED MAR shows an antibiotic
administration time of 0100 on 10-28-20xx. Surrounding documentation on the ED MAR makes clear that the 10-28-20xx date is an obvious error - Date was not
changed to 10-29-20xx. The antibiotic administration date/time would be
converted to 0100 on 10-29-20xx. Enter 2300 for Arrival Time.- ED face sheet lists arrival time of 13:20. ED Registration Time 13:25. ED Triage
Time 13:30. ED consent to treat form has 1:17 time but “AM” is circled. ED
record documentation suggests the 1:17 AM is an obvious error. Enter 13:20 for
Arrival Time.- ED ECG timed as 1742. ED Greet Time 2125. ED Triage Time 2130. There is no
documentation in the Only Acceptable Sources which suggests the 1742 is an
obvious error. Enter 1742 for Arrival Time.- In determining if there is documentation which suggests the patient was not in the hospital on a given date, sources outside of the Only Acceptable Sources list can be referenced. However, do not use dates described as hospital arrival on these sources for Arrival Date/Time.
- Examples:
- ED ECG dated/timed as 05-07-20xx 2142. ED Greet Date/Time 05-08-20xx 0125. ED Triage Date/Time 05-08-20xx 0130. EMS record shows patient was enroute at 05-08-20xx 0100. Enter 05-08-20xx for Arrival Date.
- ED ECG timed as 1742. ED Greet Time 2125. ED Triage Time 2130. EMS record shows patient was enroute at 2100. Enter 2125 for Arrival Time.
- ED face sheet noted arrival date/time as 02-27-20xx 2300. The first vitals are recorded at 02-28-20xx 0020. There is no documentation to support that the patient was not in the hospital on 02-27-200xx 2300. Enter 02-27-20xx for Arrival Date.
- ED face sheet noted arrival time as 1000. The first vitals are recorded at 1120. There is no documentation to support that the patient was not in the hospital at 1000. Enter 1000 for Arrival Time.
- ED Triage Date/Time 03-22-20xx 2355. ED rhythm strip dated/timed 03-23-20xx 0030. EMS report indicates patient was receiving EMS care from 0005 through 0025 on 03-23-20xx. Enter 03-23-20xx for Arrival Date.
- ED Triage Date/Time 06-18-20xx 0025. EMS report indicates patient arrived by
ambulance on 06-17-20xx 2355. Patient routed directly to CT. The EMS report is
disregarded. Enter 06-18-20xx for Arrival Date.- The source "Emergency Department record" includes any documentation from the time period that the patient was an ED patient (e.g., ED face sheet, ED consent/Authorization for treatment forms, ED/Outpatient Registration/sign-in forms, ED vital sign record, ED triage record, ED physician orders, ED ECG reports, ED telemetry/rhythm strips, ED laboratory reports, ED x-ray reports, ED head CT scan, CTA, MRI, MRA reports).
- The source “Procedure notes” refers to procedures such as cardiac caths, endoscopies, and surgical procedures. Procedure notes do not include ECG and x-ray reports.
- The arrival date/time may differ from the admission date/time.
- If the patient is in either an outpatient setting of the hospital other than observation status (e.g., dialysis, chemotherapy, cardiac cath) or a SNF unit of the hospital, and is subsequently admitted to acute inpatient, use the date/time the patient arrived at the ED or on the floor for acute inpatient care as the arrival date/time.
- Observation status:
- If the patient was admitted to observation from an outpatient setting of the hospital, use the date/time the patient arrived at the ED or on the floor for observation care as the arrival date/time.
- If the patient was admitted to observation from the ED of the hospital, use the date/time the patient arrived at the ED as the arrival date/time.
- Direct Admits:
- If the patient is a “Direct Admit” to the cath lab, use the earliest date/time the patient arrived at the cath lab (or cath lab staging/holding area) as the arrival date/time.
- For “Direct Admits” to acute inpatient or observation, use the earliest date/time the patient arrived at the nursing floor or in observation (as documented in the Only Acceptable Sources) as the arrival date/time.
- If the patient was transferred from your hospital’s satellite/free-standing ED or from another hospital within your hospital’s system (as an inpatient or ED patient), and there is one medical record for the care provided at both facilities, use the arrival date/time at the first facility.
- CSTK Measures only EXCEPTION: Use the arrival date/time at the comprehensive stroke center.
- For inpatient strokes, enter the actual hospital arrival date/time and not the date/time of symptom discovery (Note this is not from the definition from Specifications Manual for National Hospital Inpatient Quality Measures).
Suggested Data Sources:
ONLY ACCEPTABLE SOURCES:
- Emergency department record
- Nursing admission assessment/admitting note
- Observation record
- Procedure notes
- Vital signs graphic record
Inclusion Guidelines for Abstraction: None
Exclusion Guidelines for Abstraction: Addressographs/stamps
Element definition from Specifications Manual for National Hospital Inpatient Quality Measures
The month, day, and year of admission to acute inpatient care.
- MM = Month (01-12)
- DD = Day (01-31)
- YYYY = Year (20xx)
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
- Physician orders
- Face Sheet
- UB-04
Excluded Data Sources
UB-04 "From" and "Through" datesInclusion Guidelines for Abstraction: None
Exclusion Guidelines for Abstraction:
- Admit to observation
- Arrival date
Was patient evaluated in the ED for acute Stroke or TIA and never admitted as an inpatient to your hospital?
- Yes, not admitted: Patient was evaluated in the Emergency Department (ED), found to have a diagnosis of Ischemic Stroke, Subarachnoid Hemorrhage, Intracerebral Hemorrhage, or Transient Ischemic Attack, and was never admitted to your hospital as an inpatient. Include here patients that are transferred from the ED to another acute care hospital, those that are discharged directly from the ED to home or other location, those that leave against medical advice (AMA) from the ED, those that die in the ED, and those that are discharged from observation status without ever being admitted as an inpatient.
- No, patient admitted as inpatient: Patient was admitted 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
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:
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 = UnknownTime
HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unknown
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:
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:
UB-04, Field Number 6
Discharge Summary
Face Sheet
Nursing Discharge Notes
Physician Notes
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:
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:
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: 1Allowable 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:
- Only use documentation written on the day prior to discharge through 30 days after discharge when abstracting this data element.
Example: Documentation in the Discharge Planning notes on 04-01-20xx state that the patient will be discharged back home. On 04-06-20xx the physician orders and nursing discharge notes on the day of discharge reflect that the patient was being transferred to skilled care. The documentation from 04-06-20xx would be used to select value "5" (Other Health Care Facility).- The medical record must be abstracted as documented (taken at “face value”). Inferences should not be made based on internal knowledge.
- If there is documentation that further clarifies the level of care that documentation should be used to determine the correct value to abstract. If documentation is contradictory, use the latest documentation.
Examples:
- Discharge summary dictated 2 days after discharge states patient went “home”. Physician note on day of discharge further clarifies that the patient will be going "home with hospice”. Select value “2” (“Hospice - Home”).
- Discharge planner note from day before discharge states “XYZ Nursing Home”. Discharge order from day of discharge states “Discharge home”. Contradictory documentation, use latest. Select value “1” (“Home”).
- Physician order on discharge states “Discharge to ALF”. Discharge instruction sheet completed after the physician order states patient discharged to “SNF”. Contradictory documentation, use latest. Select value “5” (“Other Health Care Facility”).
- If documentation is contradictory, use the latest documentation. If there is documentation that further clarifies the level of care that documentation should be used to determine the correct value to abstract.
Example:
- Nursing discharge note documentation reflects that the patient is being discharged to "XYZ" Hospital. The Social Service notes from the day before discharge further clarify that the patient will be transferred to the rehab unit of "XYZ" Hospital, select value "5"
- Hospice (values “2” and “3”) includes discharges with hospice referrals and evaluations.
- If the medical record states only that the patient is being discharged to another hospital and does not reflect the level of care that the patient will be receiving, select value “4” (“Acute Care Facility”).
- If the medical record states the patient is being discharged to assisted living care or an assisted living facility (ALF) and the documentation also includes nursing home intermediate care or skilled nursing facility, select Value “1” (“Home”).
- If the medical record states the patient is being discharged to nursing home, intermediate care or skilled nursing facility without mention of assisted living care or assisted living facility (ALF),select Value “5” (“Other Health Care Facility”).
- If the medical record identifies the facility the patient is being discharged to by name only (e.g., “Park Meadows”), and does not reflect the type of facility or level of care, select value “5” (“Other Health Care Facility”).
- If the medical record states only that the patient is being “discharged” and does not address the place or setting to which the patient was discharged, select value “1” (“Home”).
- When determining whether to select value “7” (“Left Against Medical Advice/AMA”):
- Explicit “left against medical advice” documentation is not required. E.g., “Patient is refusing to stay for continued care” – Select value “7”.
- Documentation suggesting that the patient left before discharge instructions could be given does not count.
- A signed AMA form is not required, for the purposes of this data element.
- Do not consider AMA documentation and other disposition documentation as “contradictory”. If any source states the patient left against medical advice, select value “7”, regardless of whether the AMA documentation was written last. E.g., AMA form signed and discharge instruction sheet states “Discharged home with belongings” – Select “7”.
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-04Inclusion 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 facilities, 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 HospitalizationHospice – 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 HomeExclusion Guidelines for Abstraction:
None
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.
- Skilled Nursing Facility (SNF): Patient was discharged or transferred to a skilled nursing facility (SNF) previously captured as Discharge Status (03) Dsch/Trans to skilled nursing facility (SNF) and (61) Dsch/Trans to hospital-based Medicare approved swing bed. This would include patients discharged to:
- skilled nursing facility (SNF),
- SNF rehabilitation unit (a unit within the SNF),
- Sub-Acute Care,
- Transitional Care Unit (TCU),
- Swing Bed (patients discharged/ transferred to a SNF level of care within the hospital's approved swing bed arrangement), or
- Skilled nursing facility with hospice referral only (has not accepted hospice care by a hospice organization).
- Inpatient Rehabilitation Facility (IRF): Patient was discharged or transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital previously captured as Discharge Status (62) Dsch/Trans to an inpatient rehabilitation facility (IRF).
- Long Term Care Hospital (LTCH): Patient was discharged or transferred to a Medicare certified long term care hospital (LTCH or LTACH) or a nursing facility certified under Medicaid but not certified under Medicare previously captured as Discharge Status (63) Dsch/Trans to Medicare certified long term care hosp and (64) Disch/Trans to a nursing facility certified under Medicaid but not certified under Medicare. LTCH Usage Note: For hospitals that meet the Medicare criteria for LTCH certification. A Long-term care hospital or long-term care facilities provide acute inpatient care with an average length of stay greater than 25 days.
- Intermediate Care facility (ICF): Patient was discharged or transferred to an intermediate care facility (ICF) previously captured as Discharge Status (04) Dsch/Trans to a facility that provides custodial or supportive care. This would include patients discharged to:
- ECF (Extended Care Facility),
- ICF (Intermediate Care Facility),
- Nursing Home,
- Nursing facility for non-skilled/custodial/residential level of care,
- Veteran’s Administration Nursing Facility,
- Nursing facility with neither Medicare nor Medicaid certification
- Nursing facility with hospice referral only (has not accepted hospice care by a hospice organization).
- Other: The patient was discharged or transferred to a Psychiatric Hospital or Psychiatric Unit of a Hospital previously capture as Discharge Status (65) Dsch/Trans to a psychiatric hospital or psychiatric distinct part unit of a hospital or other healthcare facility not defined in above options.
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.htmlNotes 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:
- Discharge summary
- Face sheet
- UB-04
Inclusion Guidelines for Abstraction: None
Exclusion Guidelines for Abstraction: None
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.htmlNotes for Abstraction:
NoneSuggested Data Sources:
- Discharge summary
- Face sheet
- UB-04
Inclusion Guidelines for Abstraction: None
Exclusion Guidelines for Abstraction: None
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.htmlNotes for Abstraction:
NoneSuggested Data Sources:
- Discharge summary
- Face sheet
- UB-04
Inclusion Guidelines for Abstraction: None
Exclusion Guidelines for Abstraction: None
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.htmlNotes for Abstraction:
NoneSuggested Data Sources:
- Discharge summary
- Face sheet
- UB-04
Inclusion Guidelines for Abstraction: None
Exclusion Guidelines for Abstraction: None
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.htmlNotes for Abstraction:
NoneSuggested Data Sources:
- Discharge summary
- Face sheet
- UB-04
Inclusion Guidelines for Abstraction: None
Exclusion Guidelines for Abstraction: None
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.htmlNotes for Abstraction:
NoneSuggested Data Sources:
- Discharge summary
- Face sheet
- UB-04
Inclusion Guidelines for Abstraction:None
Exclusion Guidelines for Abstraction: None
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:
- Only check this box if there is no ICD-10-PCS Code documented in the medical record for this episode of care.
- If there is no ICD-10-PCS Code documented related to thrombolytics or endovascular therapy, but there is an ICD-10-PCS Code for another procedure (either stroke related or non-stroke related), then this box should not be checked.
Suggested Data Sources:
- Discharge summary
- Face sheet
- UB-04
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.
- MM = Month (01-12)
- DD = Day (01-31)
- YYYY = Year (20xx)
- UTD = Unable to Determine
Notes for Abstraction:
- If the principal procedure 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 or is outside of the parameters of care [after Discharge Date ]) and no other documentation is found that provides this information, the abstractor should select "UTD."
- Examples:
- Documentation indicates the ICD-9-CM Principal Procedure Date was 02- 42- 20XX . No other documentation in the medical record provides a valid date. Since the ICD-9-CM Principal Procedure 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 ICD-9-CM Principal Procedure Date was 03-12- 20XX . Other documentation in the medical record supports the date of death as being accurate. Since the ICD-9-CM Principal Procedure Date is after the Discharge Date (death), it is outside of the parameter 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 ICD-9-CM Principal Procedure Date allows the case to be accepted into the warehouse.
Suggested Data Sources:
- Consultation notes
- Diagnostic test reports
- Discharge summary
- Face sheet
- Operative notes
- Procedure notes
- Progress notes
- UB-04
Inclusion Guidelines for Abstraction: None
Exclusion Guidelines for Abstraction: None
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.
- MM = Month (01-12)
- DD = Day (01-31)
- YYYY = Year (20xx)
- UTD = Unable to Determine
Notes for Abstraction:
- If the principal procedure 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 or is outside of the parameters of care [after Discharge Date ]) and no other documentation is found that provides this information, the abstractor should select "UTD."
- Examples:
- Documentation indicates the ICD-10-PCS Principal Procedure Date was 02- 12- 20XX . No other documentation in the medical record provides a valid date. Since the ICD-10-PCS Principal Procedure 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 ICD-10-PCS Principal Procedure Date was 03-12- 20XX . Other documentation in the medical record supports the date of death as being accurate. Since the ICD-10-PCS Principal Procedure Date is after the Discharge Date (death), it is outside of the parameter 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 ICD-10-PCS Principal Procedure Date allows the case to be accepted into the warehouse.
Suggested Data Sources:
- Consultation notes
- Diagnostic test reports
- Discharge summary
- Face sheet
- Operative notes
- Procedure notes
- Progress notes
- UB-04
Inclusion Guidelines for Abstraction: None
Exclusion Guidelines for Abstraction: None
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: 1Allowable Values:
HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to DetermineNotes for Abstraction:
- 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 ICD-9-CM Principal Procedure Time is the time associated with the start of the principle procedure performed during the hospitalization. If a patient enters the operating room or interventional suite, but the principal procedure is canceled before it is initiated and the principal procedure performed at a later time, the ICD-9-CM Principal Procedure Time is the start time when the procedure was actually performed.
- If the start time when the principal procedure was performed 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 principal procedure start 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 start time of the ICD-9-CM Principal Procedure was 3300. No other documentation in the medical record provides a valid time. Since the start time of the ICD-9-CM Principal Procedure 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 ICD-9-CM Principal Procedure Time allows the case to be accepted into the warehouse.- If the principal procedure start time is obviously incorrect (in error) but it is a valid time and the correct time can be supported with other documentation in the medical record, the correct time may be entered. If supporting documentation of the correct time cannot be found, the medical record must be taken at face value.
Examples:
- The principal procedure start time is documented as 10:00 but other documentation in the medical record supports the correct time as 22:00. Enter the correct time of 22:00 as the ICD-9-CM Principal Procedure Time.
- The principal procedure end time of 11:58 is documented but the principal procedure start time is documented as 11:57. If no other documentation can be found to support another principal procedure start time, then it must be abstracted as 11:57 because the time is not considered invalid or outside the parameter of care.
Suggested Data Sources:
- Consultation notes
- Face sheet
- Progress notes
- Diagnostic test reports
- Operating room notes
- Procedure notes
- Administrative record
- Anesthesia record
- Circulator record
- Intraoperative record
- Procedure record
Guidelines for Abstraction
Inclusion:
Note: The procedure record is the priority data source.
- 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.
- 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.
- 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
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: 1Allowable Values:
HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to DetermineNotes for Abstraction:
- 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 ICD-10-PCS Principal Procedure Time is the time associated with the start of the principle procedure performed during the hospitalization. If a patient enters the operating room or interventional suite, but the principal procedure is canceled before it is initiated and the principal procedure performed at a later time, the ICD-10-PCS Principal Procedure Time is the start time when the procedure was actually performed.
- If the start time when the principal procedure was performed 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 principal procedure start 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 start time of the ICD-10-PCS Principal Procedure was 3300. No other documentation in the medical record provides a valid time. Since the start time of the ICD-10-PCS Principal Procedure 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 ICD-10-PCS Principal Procedure Time allows the case to be accepted into the warehouse.- If the principal procedure start time is obviously incorrect (in error) but it is a valid time and the correct time can be supported with other documentation in the medical record, the correct time may be entered. If supporting documentation of the correct time cannot be found, the medical record must be taken at face value.
Examples:
- The principal procedure start time is documented as 10:00 but other documentation in the medical record supports the correct time as 22:00. Enter the correct time of 22:00 as the ICD-10-PCS Principal Procedure Time.
- The principal procedure end time of 11:58 is documented but the principal procedure start time is documented as 11:57. If no other documentation can be found to support another principal procedure start time, then it must be abstracted as 11:57 because the time is not considered invalid or outside the parameter of care.
- For bedside procedures, e.g. external ventricular drain (EVD) placement, the time documented on the bedside flow sheet / nursing note should be used if earlier than other times documented on a procedure record or in other sources.
Suggested Data Sources:
- Consultation notes
- Face sheet
- Progress notes
- Diagnostic test reports
- Operating room notes
- Procedure notes
- Administrative record
- Anesthesia record
- Circulator record
- Intraoperative record
- Procedure record
- Bedside flow sheet
- ICU notes
- Nursing notes
- Nursing flow sheet
- Operative notes
Guidelines for Abstraction
Inclusion:
Note: The procedure record is the priority data source.
- 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).
- 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
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.htmlSuggested Data Sources:
- Discharge summary
- Face sheet
- UB-04
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
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.htmlNotes for Abstraction:
NoneSuggested Data Sources:
- Discharge summary
- Face sheet
- UB-04
Inclusion Guidelines for Abstraction: None
Exclusion Guidelines for Abstraction: None
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.
- MM = Month (01-12)
- DD = Day (01-31)
- YYYY = Year (20xx)
- UTD = Unable to Determine
Notes for Abstraction:
If the procedure date for the associated procedure 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 format/range or outside of the parameters of care [after Discharge Date ]) and no other documentation is found that provides this information, the abstractor should select "UTD."
Examples:
Documentation indicates the ICD-9-CM Other Procedure Dates was 02- 42- 20 XX . No other documentation in the medical record provides a valid date. Since the ICD-9-CM Other Procedure Dates 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 02-12-20 XX and documentation indicates the ICD-9-CM Other Procedure Dates was 03-12-20 XX . Other documentation in the medical record supports the date of death as being accurate. Since the ICD-9-CM Other Procedure Dates 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 ICD-9-CM Other Procedure Dates allows the case to be accepted into the warehouse.
Suggested Data Sources:
- Consultation notes
- Diagnostic test reports
- Discharge summary
- Face sheet
- Operative notes
- Procedure notes
- Progress notes
- UB-04
Inclusion Guidelines for Abstraction: None
Exclusion Guidelines for Abstraction: None
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.
- MM = Month (01-12)
- DD = Day (01-31)
- YYYY = Year (20xx)
- UTD = Unable to Determine
Notes for Abstraction:
If the procedure date for the associated procedure 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 format/range or outside of the parameters of care [after Discharge Date ]) and no other documentation is found that provides this information, the abstractor should select "UTD."
Examples:
Documentation indicates the ICD-10-PCS Other Procedure Dates was 02- 42- 20 XX . No other documentation in the medical record provides a valid date. Since the ICD-10-PCS Other Procedure Dates 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 02-12-20 XX and documentation indicates the ICD-10-PCS Other Procedure Dates was 03-12-20 XX . Other documentation in the medical record supports the date of death as being accurate. Since the ICD-10-PCS Other Procedure Dates 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 ICD-10-PCS Other Procedure Dates allows the case to be accepted into the warehouse.
Suggested Data Sources:
- Consultation notes
- Diagnostic test reports
- Discharge summary
- Face sheet
- Operative notes
- Procedure notes
- Progress notes
- UB-04
Inclusion Guidelines for Abstraction: None
Exclusion Guidelines for Abstraction: None
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: 24Allowable Values:
HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to DetermineNotes for Abstraction:
- 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 ICD-9-CM Other Procedure Times are the time(s) associated with the start of procedures performed after the principal procedure. If a patient enters the operating room or interventional suite, but the procedure is canceled before it is initiated and the procedure performed at a later time, the ICD-9-CM Other Procedure Times are the start time(s) when the procedure(s) were actually performed.
- If the procedure start 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 procedure start 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 procedure start time was 3300. No other documentation in the medical record provides a valid time. Since the procedure start 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 ICD-9-CM Other Procedure Times allows the case to be accepted into the warehouse.- If the procedure start time is obviously incorrect (in error) but it is a valid time and the correct time can be supported with other documentation in the medical record, the correct time may be entered. If supporting documentation of the correct time cannot be found, the medical record must be taken at face value.
Examples:
- The procedure start time is documented as 10:00 but other documentation in the medical record supports the correct time as 22:00. Enter the correct time of 22:00 as the ICD-9-CM Other Procedure Time(s).
- The procedure end time of 11:58 is documented but the procedure start time is documented as 11:57. If no other documentation can be found to support another procedure start time, then it must be abstracted as 11:57 because the time is not considered invalid or outside the parameter of care.
Suggested Data Sources:
- Consultation notes
- Face sheet
- Progress notes
- Diagnostic test reports
- Operating room notes
- Procedure notes
- Administrative record
- Anesthesia record
- Circulator record
- Intraoperative record
- Procedure record
Guidelines for Abstraction
Inclusion:
Note: The procedure record is the priority data source.
- 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).
- 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).
- 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
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: 24Allowable Values:
HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to DetermineNotes for Abstraction:
- 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 ICD-10-PCS Other Procedure Times are the time(s) associated with the start of procedures performed after the principal procedure. If a patient enters the operating room or interventional suite, but the procedure is canceled before it is initiated and the procedure performed at a later time, the ICD-10-PCS Other Procedure Times are the start time(s) when the procedure(s) were actually performed.
- If the procedure start 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 procedure start 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 procedure start time was 3300. No other documentation in the medical record provides a valid time. Since the procedure start 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 ICD-10-PCS Other Procedure Times allows the case to be accepted into the warehouse.- If the procedure start time is obviously incorrect (in error) but it is a valid time and the correct time can be supported with other documentation in the medical record, the correct time may be entered. If supporting documentation of the correct time cannot be found, the medical record must be taken at face value.
Examples:
- The procedure start time is documented as 10:00 but other documentation in the medical record supports the correct time as 22:00. Enter the correct time of 22:00 as the ICD-10-PCS Other Procedure Time(s).
- The procedure end time of 11:58 is documented but the procedure start time is documented as 11:57. If no other documentation can be found to support another procedure start time, then it must be abstracted as 11:57 because the time is not considered invalid or outside the parameter of care.
- For bedside procedures, e.g. external ventricular drain (EVD) placement, the time documented on the bedside flow sheet / nursing note should be used if earlier than other times documented on a procedure record or in other sources.
Suggested Data Sources:
- Consultation notes
- Face sheet
- Progress notes
- Diagnostic test reports
- Operating room notes
- Procedure notes
- Administrative record
- Anesthesia record
- Circulator record
- Intraoperative record
- Procedure record
- Bedside flow sheet
- ICU notes
- Nursing notes
- Nursing flow sheet
- Operative notes
Guidelines for Abstraction
Inclusion:
Note: The procedure record is the priority data source.
- 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).
- 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
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: 1Allowable 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:
- The admitting diagnosis is defined as the initial working diagnosis documented by the patients admitting or attending physician who determined that inpatient care was necessary.
Suggested Data Sources:
- Face sheet
- Admission form
- Code List
- Problem list
Guidelines for Abstraction
Inclusion: None
Exclusion: None
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: 1Allowable Values: Any valid ICD-10-CM diagnosis code
Notes for Abstraction:
- The admitting diagnosis is defined as the initial working diagnosis documented by the patients admitting or attending physician who determined that inpatient care was necessary.
Suggested Data Sources:
- Face sheet
- Admission form
- Code List
- Problem list
Guidelines for Abstraction
Inclusion: None
Exclusion: None
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.
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.
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
Arrival and Admission Information
Required for TJC, GWTG- Stroke, And COVERDELL users (used as a standard exclusion in measures)
Collected For: CSTK-04, CSTK-06, STKLength: 1
Type: Alphanumeric
Occurs: 1
Allowable Values:
Notes for Abstraction:
In the following situations, select "No":
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
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).
- Yes (There is documentation that this admission was solely for the performance of elective carotid intervention.)
- No (There is no documentation that this admission was solely for the performance of elective carotid intervention, OR unable to determine from medical record documentation.)
Notes for Abstraction
- When documentation clearly indicates that the carotid intervention is elective (e.g.,
admitting orders to obtain informed consent for a carotid procedure; pre-operative
testing completed prior to admission; surgical orders for carotid endarterectomy dated
prior to arrival; physician office visit documentation prior to arrival stating, “CEA with
Dr. X planned in the near future”), select “Yes.”- Patients who are sent to the hospital by their physician and admitted for performance
of a carotid intervention, select “Yes.”- Patients admitted to the hospital for purposes of performance of a carotid intervention
and the intervention cancelled/postponed during the hospital stay, select “Yes.”- Patients who request admission to the hospital for performance of a carotid
intervention, select “Yes.”- Patients transferred to the hospital for purposes of surgical evaluation for performance
of a carotid intervention, select “Yes.”- When the patient is directly admitted to the hospital post-procedure following an
elective carotid intervention performed as an outpatient, select “Yes.”
Example:
Patient scheduled for elective carotid endarterectomy right side on 05/17/20xx at
08:30. Patient checks into outpatient surgery at 06:13 and proceeds to the O.R., then
to PACU. Patient status is changed to inpatient at 11:35 on 05/17/20xx. Patient
discharged home on 05/18/20xx.- EXCEPTION:
Patients with documentation of an elective carotid intervention performed and
discharged from the outpatient setting prior to hospital admission for stroke.
Example:
Pt. scheduled for outpatient placement of an elective right carotid stent on 05/17/20xx.
Patient discharged home on 05/17/20xx following the procedure. Patient arrives in the
ED two days later with complaints of syncope and left-sided numbness, and is
admitted to the hospital on 05/19/20xx.- Patients who are symptomatic and come to the ED for treatment of stroke signs and
symptoms and then admitted to the hospital are not considered elective admissions,
even if a carotid intervention was performed after admission, select “No.”- When documentation of the procedure is not linked with “elective,” select “No.”
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-upPatients 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.
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.
- Not in a healthcare setting
- Another acute care facility
- Chronic healthcare facility
- Outpatient healthcare setting
- Stroke occurred after hospital arrival (in ED/Obs/inpatient)
- ND or Cannot be determined
Notes for Abstraction
- If the patient was a resident of a nursing home, but was out with family for the day and suffered a stroke and the family/EMS brought the patient to your hospital, choose "Not in a healthcare setting".
- If the patient was at home, at work, or even a visitor in your hospital and had stroke symptoms, then choose "Not in a healthcare setting".
- If the patient was transferred to your hospital from another hospital’s ED or inpatient unit but was outside of a healthcare facility when the stroke occurred, choose "Not in a healthcare setting".
- If the patient was a resident of a nursing home and the stroke occurred at the NH, choose "Chronic healthcare facility".
- A chronic care facility would include nursing home, long-term care facility, inpatient rehab facility, psychiatric hospital, and transitional care unit. This is in alignment with the designation of this type of facility as Value 5-Other Healthcare Facility for the Discharge Disposition data element.
- If the patient was a resident of an assisted living facility, and the stroke occurred at the assisted living facility, choose "Not in a healthcare setting." This is in alignment with the designation of an assisted living facility as Value 1- Home for the Discharge Disposition data element.
- If the patient is at a clinic or physician office visit, or at your hospital but receiving outpatient procedure or service that did not require the patient to be admitted as an inpatient, select "Outpatient healthcare setting".
- If the patient was already admitted as an inpatient in your hospital when stroke symptoms were first discovered choose "Stroke occurred after hospital arrival (in ED/Obs/inpatient)".
- If the patient was already within your hospital ED, radiology suite, or observation unit and experienced a new onset of stroke symptoms, then choose "Stroke occurred after hospital arrival (in ED/Obs/inpatient)".
- Only those hospitals that are interested in collecting information regarding inpatient stroke care should enter these patients. Patients who have transient symptoms that are present on arrival to the ED but resolve, and then later return during the hospitalization and meet criteria for ischemic stroke should all be entered as inpatient strokes.
Pre-hospital Data, Admission Data
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.Notes for Abstraction:
Referring hospital discharge date/time
Optional fieldLength: 15 MM-DD-YYYY :HH-MM (with or without colon & includes dashes) or Unkonwn
Type: Date and Time
Occurs: 1
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
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
Specify the referring hospital name
Optional field Note: This field is enabled when How patient arrived at your hospital = Transfer from other hospitalReferring 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
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
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
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:
Was the patient an ED patient at the facility?
REQUIRED FOR TJC, COMPREHENSIVE & ASRED: (Abstraction Guidelines for ED Measures Only)
Was the patient a direct admission to the hospital?
Collected For: GWTG,ICHCollected 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: 1Allowable 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:
- For patients taken directly to the operating room or interventional suite and admitted to a hospital bed post-procedure, select "YES".
- For patients admitted directly to intensive care or another hospital unit, select "YES".
- For patients who arrive at the hospital emergency department, select "NO".
Suggested Data Sources:
- Face sheet
- Progress notes
- Nursing flow sheet
- Physician orders
- Operating room record
- Procedure reports
- Transfer note
In which settings were care delivered? Select all that apply.
Collected For: GWTG,ICHIf the patient was not cared for in a dedicated stroke unit, was a formal inpatient consultation from a stroke expert obtained?
Collected For: GWTG,ICHREQUIRED: 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.Suggested Data Sources:
Pre-hospital Data
Admission Data
Admission Data
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.
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.
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:
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction:
Suggested Data Sources:
Additional Notes / Guidelines for Abstraction: N/A
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:
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction:
Suggested Data Sources:
Additional Notes / Guidelines for Abstraction: N/A
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:
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction: N/A
Suggested Data Sources: N/A
Additional Notes / Guidelines for Abstraction: N/A
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
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:
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)
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:
Suggested Data Sources:
Admission Data, UB-92/UB-04, Field Location: 14.
Definition: Indicate if the patient is homeless.
Allowable Values:
Notes for Abstraction:
Suggested Data Sources:
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."
Administrative Data:UB-04, Field Location: 09 (line 2d); Medical Record: Face sheet
Indicate the health insurance payer status for this patient.
Notes for Abstraction:
Suggested Data Sources:
Additional Notes/ Guidelines for Abstraction: N/A
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
Notes for Abstraction:
The data element, Race, is required in addition to this data element.
Suggested Data Sources:
Additional Notes / Inclusion Guidelines for Abstraction:
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.
Notes for Abstraction: If the patient did not identify a subcategory, leave this field blank
Admission Data
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.
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:
Notes for Abstraction:
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:
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:
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) |
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
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:
Notes for Abstraction:
Suggested Data Sources:
Additional Notes / Guidelines for Abstraction Inclusion:
Exclusion:
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
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:
Admission Data
- For inpatient stroke, select "No" since time of presentation (for stroke) = time of symptom discovery.
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:
Admission Data
- 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".
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
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
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
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:1Allowable Values:
Score = XX (0-42)
UTD = Unable to DetermineNotes 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
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: 1Allowable 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
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: 1Allowable 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 DetermineNotes 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
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:
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
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.
Notes for Abstraction:
Examples:
Admission Data
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.
Pre-hospital Data, Emergency Department Data, Admission Data
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: 1Allowable 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:
Suggested Data Sources:
Additional Notes
Guidelines for Abstraction
Inclusion:
Exclusion:
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: 1Allowable 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?
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.
Emergency Department Data, Admission Data
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: 1Allowable 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 DetermineNotes 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
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 posturingSuggested Data Collection Question: Was an initial Hunt and Hess scale done at this hospital?
Format
Length: 1
Type: Alphanumeric
Occurs: 1Allowable 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
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.Emergency Department Data, Admission Data
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: 1Allowable 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 DetermineNotes 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
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
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)
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):
Admission Data, Hospitalization Data
REQUIRED FOR COVERDELL ONLY: Antihypertensive
Is there documentation that the patient was on any antihypertensive medication prior to hospital arrival?
Notes for Abstraction:
Admission Data, Hospitalization Data
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
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:
Notes for Abstraction:
Suggested Data Source:
Additional Notes/ Guidelines for Abstraction: N/A
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:
Notes for Abstraction:
Suggested Data Sources:
Additional Notes/ Guidelines for Abstraction: N/A
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?Notes for Abstraction:
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
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
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
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
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
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
REQUIRED: Date/Time patient last known to be well?
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.
Notes for Abstraction:
Examples:
Admission Data, Hospitalization Data
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
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".
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
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
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
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
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
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:
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
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
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.
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.
General notation for this section:
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 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:
Notes for Abstraction:
Suggested Data Sources:
Additional Notes / Guidelines for Abstraction:
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
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:
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction:
Suggested Data Sources:
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:
Suggested Data Sources:
Guidelines for Abstraction
Inclusion: None
Exclusion: None
REQUIRED: Documented Contraindications or Warnings for not initiating IV thrombolytic in the 0-3hr treatment window?
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:
Examples:
OPTIONAL: Documented Contraindications or Warnings for not initiating IV thrombolytic in the 3-4.5hr treatment window?
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:
Examples:
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):
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:
Notes for Abstraction:
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:
Examples:
Admission Data, Hospitalization Data
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.
Notes for Abstraction:
Examples:
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:
3-4.5 hr treatment window:
Notes for Abstraction:
Example:
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:
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:
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:
Notes for Abstraction: (For 60, 45, and 30 minute reason for delay questions above)
Select the specific reason(s) documented in the medical record for the delay in administration of IV alteplase at this hospital.
Eligibility Reasons:
Medical Reasons:
Notes for Abstraction:
The following should help abstractors in classifying reasons:
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.
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:
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction: N/A
Suggested Data Sources:
Additional Notes / Guidelines for Abstraction: N/A
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
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
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
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: 1Allowable 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 DetermineNotes 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?
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: 1Allowable 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 DetermineNotes 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
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: 1Allowable 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
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: 1Allowable 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 DetermineNotes 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: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.
- 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.
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
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: 1Allowable Values:
1 Proximal cerebral occlusion
2 Distal cerebral occlusion
3 Neither proximal or distal, OR unable to determine (UTD) from the medical record documentationNotes 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 ArteryDISTAL:
• 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
• P3None
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: 1Allowable 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
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
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: 1Allowable 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
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
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
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:1Allowable Values:
Score = 0-42
UTD = Unable to DetermineNotes 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
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: 1Allowable Values:
Score = 0-42
UTD = Unable to DetermineNotes 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
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: 1Allowable Values:
Score = 0-42
UTD = Unable to DetermineNotes 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
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: 1Allowable Values:
Score = 0-42
UTD = Unable to DetermineNotes 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
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: 1Allowable 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
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: 1Allowable 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 DetermineNotes 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
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: 1Allowable 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)
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: 1Allowable 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
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: 1Allowable 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.
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: 1Allowable 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
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: 1Allowable 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 DetermineNotes 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
Other In-Hospital Treatments and Screening
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
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
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
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
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:
Notes for Abstraction:
Suggested Data Sources:
PHARMACOLOGICAL AND MECHANICAL
Inclusion Guidelines for Abstraction: Refer to Appendix H, Table 2.1 VTE Prophylaxis Inclusion Table.
Exclusion Guidelines for Abstraction: None
Admission Data, Hospitalization Data
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:
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.
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:
SUGGESTED DATA SOURCES:
ONLY PHYSICIAN/APN/PA OR PHARMACIST DOCUMENTATION OF A REASON FOR NOT ADMINISTERING VTE PROPHYLAXIS:
Additional Notes: None
Guidelines for Abstraction:
Inclusion |
Exclusion |
None Refer to Appendix H, Table 2.7 Anticoagulation Therapy for Atrial Fibrillation and Other Conditions. |
|
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:
Notes of Abstraction:
Additional Notes / Guidelines for Abstraction:
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.
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.
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
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:
Admission Data, Hospitalization Data, Emergency department record, Nursing notes, Nusing flow sheet, Progress notes, Physician ordres, Medication administration record (MAR)
Excluded Data Sources
Additional Notes:
Guidelines for Abstraction:
Inclusion
Exclusion
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.
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
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
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: 1Allowable 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
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: 1Allowable 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
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: 1Allowable 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)
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: 1Allowable 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
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:
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: 1Allowable 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
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):
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:
Suggested Data Sources:
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.
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:
Notes for Abstraction:
Suggested Data Sources:
Additional Notes / Guidelines for Abstraction:
^^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: |
|
||||||
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. |
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: |
|
||||||
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: |
|
||||||
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: |
|||||||
|
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: |
|
||||||
Allowable Values: |
Date Time HH = Hour (00-23) 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:
Note: When converting Midnight or 24:00 to 00:00, do not forget to change the First Radiographic Image Date. |
||||||
Notes for Abstraction: |
|
||||||
Suggested Data Sources: |
· Consultation notes · Diagnostic test reports · Procedure notes * Operative notes · Procedure report |
||||||
Additional Notes: |
|||||||
Guidelines for Abstraction: |
|||||||
|
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: |
|
||||||
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. |
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: |
|
||||||
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. |
Data Element Name: |
First Pass of a Mechanical Reperfusion Device |
||||||
Collected For: |
|||||||
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: |
|
||||||
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: |
|||||||
|
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: |
|
||||||
Allowable Values: |
Date Time HH = Hour (00-23) 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:
Note: When converting Midnight or 24:00 to 00:00, do not forget to change the First Radiographic Image Date. |
||||||
Notes for Abstraction: |
|
||||||
Suggested Data Sources: |
· Consultation notes · Diagnostic test reports · Procedure notes * Operative notes · Procedure report |
||||||
Additional Notes: |
|||||||
Guidelines for Abstraction: |
|||||||
|
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: |
|
||||||
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. |
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: |
|
||||||
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.
|
||||||
Suggested Data Sources: |
· Consultation notes · Diagnostic test reports · Operative notes · Operative report · Procedure notes · Procedure report |
||||||
Additional Notes: |
None |
||||||
Guidelines for Abstraction: None. |
Data Element Name: |
Proximal or Distal Occlusion |
||||||
Collected For: |
|||||||
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: |
|
||||||
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: |
|||||||
|
Note:
Data Element Name: |
Similar GWTG® element appears under the Hospitalization Tab Site of Primary Vessel Occlusion |
Collected For: |
|
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: |
|
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
|
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: |
|
Notes for Abstraction: |
|
Suggested Data Sources: |
· Consultation notes · Diagnostic test reports · Procedure reports |
Additional Notes / Guidelines for Abstraction:
|
|
Data Element Name: |
Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade |
Collected For: |
|
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:
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:
Notes for Abstraction:
Suggested Data Sources:
Additional Notes / Guidelines for Abstraction:
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:
Notes for Abstraction:
Suggested Data Sources:
Additional Notes / Guidelines for Abstraction:
^Date/Time of positive brain image:
Data Element Name: |
Positive Brain Image Date and Time |
|||||||||||||
Collected For: |
||||||||||||||
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: |
|
|||||||||||||
Allowable Values: |
HH = Hour (00-23)
|
|||||||||||||
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.
· 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: |
|||||||||||||
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: |
^^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
|
Data Element Name: |
NIHSS Score Documented Closest to IV Thrombolytic Initiation |
|||||||
Collected For: |
||||||||
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: |
|
|||||||
Allowable Values: |
|
|||||||
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. 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: |
||||||||
|
Data Element Name: |
Highest NIHSS Score Documented Within 36 Hours Following IV Thrombolytic Initiation |
|||||||
Collected For: |
||||||||
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: |
|
|||||||
Allowable Values: |
|
|||||||
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. 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: |
||||||||
|
^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: |
||||||||
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: |
|
|||||||
Allowable Values: |
|
|||||||
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. 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: |
||||||||
|
Data Element Name: |
Highest NIHSS Score Documented Within 36 Hours Following IA alteplase or MER Initiation |
|||||||
Collected For: |
||||||||
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: |
|
|||||||
Allowable Values: |
|
|||||||
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. 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: |
||||||||
|
^Is there documentation that a procoagulant reversal agent was initiated at this hospital?
Data Element Name: |
Procoagulant Reversal Agent Initiation |
|||||||
Collected For: |
||||||||
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: |
|
|||||||
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: |
||||||||
|
^^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: |
|
||||||||||||||
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: |
||||||||
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: |
|
|||||||
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.
· 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: |
||||||||
|
^^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: |
|
||||||||||||||
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 |
^Is there documentation that nimodipine was administered at this hospital?
Required for TJC CSTK Users
Data Element Name: |
Nimodipine Administration |
|||||||
Collected For: |
||||||||
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: |
|
|||||||
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: |
||||||||
|
^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: |
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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. |
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Data Collection Question: |
What is the date and time of nimodipine administration for this patient at this hospital? |
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Format: |
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Allowable Values: |
· Date and Time (military time) · Date only · Unknown |
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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. · 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:
· 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. |
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Suggested Data Sources: |
· Emergency department record · Nursing flow sheet · Progress notes · Medication administration record (MAR) · Medical transport records · Medication reconciliation form |
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Additional Notes: |
None. |
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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 |
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Collected For: |
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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. |
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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? |
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Format: |
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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. |
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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. · 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. |
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Suggested Data Sources: |
· Emergency department record · Nursing flow sheet · Progress notes · Medication administration record (MAR) · Medication reconciliation form |
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Additional Notes: |
Excluded Data Sources: · Any documentation dated/timed later than 24 hours after hospital arrival. |
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Guidelines for Abstraction: |
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^^Surgical treatment for ICH at this hospital?
Data Element Name: |
Surgical treatment for ICH at this hospital |
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Collected For: |
GWTG ® Data Element, Optional field |
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Definition: |
Indicate if surgical treatment was initiated at this hospital for ICH. |
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Data Collection Question: |
Surgical treatment for ICH at this hospital? |
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Format: |
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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 |
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Notes for Abstraction: |
· None. |
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Suggested Data Sources: |
· Emergency department record · Nursing flow sheet · Progress notes · Medication administration record (MAR) · Medication reconciliation form |
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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 |
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Collected For: |
GWTG ® Data Element, Optional field |
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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) |
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Data Collection Question: |
^^ If surgical treatment for ICH at this hospital, type |
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Format: |
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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 |
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Notes for Abstraction: |
· None. |
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Suggested Data Sources: |
· Progress notes · Medication reconciliation form Consultation notes · Emergency department record · Discharge summary |
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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 |
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Collected For: |
GWTG ® Data Element, Optional field |
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Definition: |
The total hours from the onset of stroke to the start of the surgical procedure. |
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Data Collection Question: |
^^If ICH was evacuated, time from ictus to evacuation procedure start was: |
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Format: |
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Allowable Values: |
· Indicate the time, in hours, between ictus and surgery. |
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Notes for Abstraction: |
· The start of surgery is defined as the time documented in the operative or procedure note. |
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Suggested Data Sources: |
· Progress notes · Medication reconciliation form Consultation notes · Emergency department record · Discharge summary |
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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.
Notes for Abstraction:
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:
Suggested Data Sources:
Excluded Data Sources:
Guidelines for Abstraction
Inclusion: None
Exclusion: None
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
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:1Allowable Values:
PLT = platelet count value (no commas, no decimal)
UTD = Unable to DetermineNotes 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
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:
- Enter the first INR value performed after hospital arrival.
- For patients treated with procoagulant, if no INR value is documented as being performed prior to procoagulant initiation, select “ND.” See Comprehensive: Is there documentation that a procoagulant reversal agent was initiated at this hospital? for list of procoagulant medications.
- For inpatient strokes, enter INR value obtained after discovery of stroke symptoms.
Hospitalization Data
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: 1Allowable 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
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: 1Allowable Values:
BP = systolic and diastolic blood pressure values
UTD = Unable to DetermineNotes 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
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
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.
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
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
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:
Notes for Abstraction:
Suggested Data Sources:
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
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction:
Suggested Data Sources:
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.
Notes for Abstraction:
Suggested Data Sources:
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:
Notes for Abstraction:
Suggested Data Sources:
Hospitalization Data, Discharge Data
REQUIRED: Antithrombotic Therapy approved in stroke
Prescribed: Was antithrombotic medication approved in stroke prescribed at discharge?
Notes for Abstraction:
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) |
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.
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.
If "Yes" is selected, a class (Antiplatelet or Anticoagulant) and medication is required.
Recording the dosage and frequency are OPTIONAL.
Examples:
Hospitalization Data, Discharge Data
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.
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):
Hospitalization Data, Discharge Data
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
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
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.
Hospitalization Data, Discharge Data
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
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
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.0000000000000625Hospitalization Data, Discharge Data
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
Documented Reason for Not Prescribing a Statin Medication at Discharge
Collected For: STK-6
Definition: 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.
Question: Is there documentation of a reason for not prescribing a statin medication at discharge?
Format: Single Select
Allowable Values:
Notes for Abstraction:
Suggested Data Sources:
Additional Notes / Guidelines for Abstraction:
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