Get with the Guidelines® - Stroke PMT®

Abstraction Guidelines Updated August 2022

Print Coding Instructions

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Table of Contents

• Entry Criteria
• Demographics Tab
• Race and Ethnicity
• Admin Tab
• Clinical Codes
• Admission Tab
• Discharge Diagnoses
• Arrival and Admission Information
• Telestroke
• Telestroke Time Tracker
• Medical History
• Diagnosis and Evaluation
• Medications Prior to Admission
• Vaccinations & Testing
• Hospitalization Tab
• Symptom Timeline
• Brain Imaging
• Additional Time Tracker
• IV Thrombolytic Therapy
• Endovascular Therapy
• Complications of Thrombolytic Therapy
• Other In-Hospital Treatment and Screening
• Measurements (first measurement upon presentation to your hospital)
• Advanced Stroke Care Tab
• Endovascular Stroke Treatment
• Complications
• Hemorrhagic Stroke Treatment [only for CSTK users]
• Discharge Tab
• Discharge Information
• Discharge Treatments
• Other Lifestyle Interventions
• Stroke Education
• Stroke Rehabilitation
• Health Related Social Needs Assessment
• Stroke Diagnostic Tests and Interventions
• Post Discharge Follow-up Form
• Optional Fields
• Administrative
• Additional TJC Stroke Core Measure Fields
• Special Initiatives (Prehospital Care Tab)
• PSC Optional Fields
• Administrative
• Table 1 - Antihypertensive Medications
• Table 2 - Cholesterol Reducing/Controlling medications
• Table 3 - Characteristics of Patients With Ischemic Stroke Who Could Be Treated With rtPA in the 0 - 3 hour time window
• Table 4 - Antiplatelet Medication
• Table 5 - Anticoagulant Medication
• Table 6 - Statin Dose and Intensity
• Table 7 - Anti-hyperglycemic medications
• Summary of Changes

Entry Criteria

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

• Cerebral Infarction
• Intracerebral Hemorrhage (non-traumatic)
• Ischemic Stroke
• Stroke
• Subarachnoid Hemorrhage (non-traumatic)
• Transient Ischemic Attack (TIA)

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

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:

• Patients initially admitted to the hospital for one of the diagnoses even if they later transfer or expire.
• Patients directly admitted to nursing units within the hospital without first being seen in the Emergency Department (ED). This includes patients with acute ischemic stroke who receive treatment at another hospital and are transferred to your hospital.
• Patients who refuse treatment or who have Do Not Resuscitate orders.
• Patients evaluated and treated in the ED with the intention of being admitted, even if they expire, leave against medical advice, or are subsequently transferred to another acute care hospital prior to being admitted to the hospital (this would include patients that receive IV tPA at your hospital and are then transferred for further management ("drip and ship patients").

Optional:

• Patients who have an in-hospital stroke. Please note in-hospital strokes are excluded from all Achievement Measures, but are included in the GWTG Inpatient stroke measures.
• Patients who present with stroke-like symptoms but who do not end up being diagnosed with a stroke or TIA (stroke mimics).
• Patients evaluated, treated, and discharged from the ED (with no inpatient admission) to home or another location that is not an acute care hospital.
• Patients discharged from observation status with no inpatient admission.
• Patients admitted for the sole purpose of the performance of elective carotid endarterectomy or any revascularization. This type of patient would typically be excluded from GWTG-Stroke. Only enter this type of patient if needed to comply with TJC (or other) sampling plan or data entry requirements.

Exclude:

• Patients < 18 years of age.

Summary of Changes

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

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

General notation:

• ND = Not Documented. Select ND when there is no documentation in the medical record to explain why a treatment or intervention is not performed.
• NC = None-Contraindicated. Select NC when a reason for non-treatment was documented in the medical record (e.g. not indicated, contraindicated, patient/family refused).
• UTD = Unable to determine.
• TJC = The Joint Commission
• PSC = Primary Stroke Center
• IV alteplase (or IV rt-PA) = Intravenous Tissue Plasminogen Activator
• PMT = Patient Management Tool

Abstraction Guidelines:

• Do not enter any personal health information/protected health information (PHI) in any free text "Comments" fields or Optional Fields 1-10, 11, & 12.
• Make use of the Suggested Sources for Abstraction as a guide to help find medical documentation for each data element. Only abstract data which is clearly documented in the medical records. When in doubt, consult with your local Stroke champion or Stroke team leader for clarification.
• When there is a discrepancy in documentation status or a patient's specific variable, refer to the source of medical higher authority relevant to that variable.
• Date Precisions: Date and Time fields have an additional "Precision" drop-down right above the MM/DD/YYYY HH:MI blanks. The Precision is used to indicate how much of the Date and Time data is known and can be abstracted. For most of the Stroke Date and Time fields, there are three Precision levels.
  
  • The default level is "MM/DD/YYYY HH:MI". This is used if the entire Date and Time information is available. Time should be entered in 24hr/Military format.



• If the Time is ND, select a Precision of "MM/DD/YYYY". The "HH:MI" blanks will become grayed-out.



• If the Date is ND, select a Precision of "Unknown". The whole "MM/DD/YYYY HH:MI" field will become grayed-out.

Summary of Changes

Suggested Sources:

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

Admission Data may include:

• Admission sheet
• Physician documentation (including Admitting physician notes, consultation notes, ED physician notes, Physician's hospital admission, transfer, or ED discharge notes, progress notes)
• ED documentation (including ED nurse notes, ED order sets or pathway documentation, ED physician notes, ED record, ED triage sheet, Registration form, ED vital signs graphical record)
• Inpatient documentation (including physician notes, history and physical, medication documentation, nurse progress notes, nursing admission assessment note, physical or occupational therapy consultation or progress notes, speech pathology consultation or progress notes, diet or nutrition services consultation or progress notes)

Hospitalization Data may include:

• Physician documentation (including Acute physician or nursing notes, Acute Stroke Pathway documentation, Consultation progress notes, Diagnostic report, Physician progress notes, Progress notes)
• Inpatient documentation (including physician notes, history and physical, medication documentation, nurse progress notes, nursing admission assessment note, physical or occupational therapy consultation or progress notes, speech pathology consultation or progress notes, diet or nutrition services consultation or progress notes)
• Medication Results (including Medication order sheets, Medication ordering system in the computer)
• Orders (including Physician order sheets, Printed or Electronic order sheets, rt-PA Protocol Sheets)
• Lab Results
• Social services notes

Discharge Data may include:

• Care plans
• Clinical logs
• Clinician encounter sheets
• Consultant reports
• Discharge face sheet
• Discharge form
• Discharge instruction sheet
• Discharge orders
• Discharge summary
• Flow sheets
• Multidisciplinary progress notes
• Nursing discharge notes
• Physician summary
• Referral notes
• Teaching sheets
• Transfer note
• Transfer record
• Physical or occupational therapy consultation or progress notes
• Diet or nutrition services consultation or progress notes

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:

• Alpha-numeric field
• Up to 20 characters max

Allowable values:

• Customized for each site
• Once created, number is case-sensitive

Notes for Abstraction:

• If a patient has not been entered in the tool, please following the mapping rules provided by your site to create a unique number for the patient.
• When creating a new Patient ID, do not use date of birth, social security numbers, and/or other identifiers associated directly with the patient. Recommendation is to create a random number in PMT that corresponds to a specific patient on your end.
• If patient information has previously been entered in the PMT, access the "Patients" tab and locate the patient. Then, under the Patient Management Tool column, select "next admission" to create a new admission for the same patient.

Sources for Data:

• Site Coordinator for instructions for mapping between internal hospital tool and the Patient Management tool.

Admin Tab

• Final clinical diagnosis related to stroke
• If No Stroke Related Diagnosis
• Was an etiology documented in the patient medical record as the most likely cause of ischemic stroke?
• Select documented Stroke Etiology
• When is the earliest documentation of comfort measures only?
• Arrival Date/Time
• Admit Date
• Not admitted
• Reason Not Admitted:
• If Patient Transferred from your ED to another hospital, specify hospital name:
• Select Reason(s) for why patient transferred
• Discharge Date and Time
• Documented reason for delay in transfer to referral facility?
• Specific reason for delay documented in transfer patient (check all that apply):
• For patients discharged on or after 04/01/2011: What was the patient’s discharge disposition on the day of discharge?
• If Other Health Care Facility

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

Summary of Changes

OPTIONAL: If No Stroke Related Diagnosis

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

• 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

Summary of Changes

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

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

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

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

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

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

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

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

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

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

• Dissection: Select this option when arterial dissection was identified as the cause of the stroke.
• Hypercoagulability: Select this option when a hypercoagulable disorder was identified as the cause of stroke.
• Other: Select this option when another cause which is neither dissection nor hypercoagulabiity is identified as the cause of stroke.

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:

• Multiple potential etiologies identified: Select this option when following diagnostic evaluation, a single etiology is uncertain between two or more possible causes.
• Stroke of undetermined etiology: Select this option when a potential etiology was not identified or documented following diagnostic evaluation.
• Unspecified: Select this option when there is no documentation of the results of the diagnostic evaluation.

Examples:

• Final diagnosis is "ischemic stroke"; atrial fibrillation documented in medical history section of medical record, but there is no documentation of a diagnostic workup or underlying cause of the ischemic stroke. Because there is no documentation stating atrial fibrillation or other condition as underlying cause and no diagnostic workup, select No for Was an etiology documented in the patient medical record as the most likely cause of stroke?
• Final diagnosis "ischemic stroke presumably due to atrial fibrillation"; cardiac ultrasound and cardiac monitoring tests performed. In this example diagnostic tests were performed and atrial fibrillation was stated as the most likely underlying cause for stroke. Select Yes for Was an etiology documented in the patient medical record as the most likely cause of stroke? and Cardioembolism as the stroke etiology.
• Final diagnosis is "ischemic stroke"; carotid ultrasound shows ICA occlusion (approx. 60% occlusion). Because there is no documentation stating ICA occlusion as the underlying cause of the stroke, select No for Was an etiology documented in the patient medical record as the most likely cause of stroke?
• Final diagnosis is "ischemic stroke, cause unknown"; no diagnostic test performed. Select Yes for Was an etiology documented in the patient medical record as the most likely cause of stroke? Select Cryptogenic Stroke and Stroke of undetermined etiology for the stroke etiology.
• Final diagnosis is "ischemic stroke" and work up reveals both carotid occlusion and atrial fibrillation as potential causes. Select Cryptogenic Stroke and Multiple potential etiologies identified.

Summary of Changes

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

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

• Day 0 or 1
• Day 2 or after
• Timing unclear
• Not Documented/UTD

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.

• Day 0 or 1: The earliest day the physician/APN/PA documented comfort measures only was the day of arrival (Day 0) or day after arrival (Day 1).
• Day 2 or after: The earliest day the physician/APN/PA documented comfort mesures was two or more days after arrival day (Day +2).
• Timing unclear: There is physician/APN/PA documentation of comfort measures only during this hospital stay, but whether the earliest documentation of comfort measures only was on day 0 or 1 OR after day 1 is unclear.
• Not documented/UTD: There is no physician/APN/PA documentation of comfort measures only, or unable to determine from medical record information.

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

Summary of Changes

REQUIRED: Admit Date

Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

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

• MM = Month (01-12)
• DD = Day (01-31)
• YYYY = Year (20xx)

Notes for Abstraction:

• The intent of this data element is to determine the date that the patient was actually admitted to acute inpatient care. Because this data element is critical in determining the population for all measures, the abstractor should NOT assume that the claim information for the admission date is correct. If the abstractor determines through chart review that the date from billing is incorrect, for purposes of abstraction, she/he should correct and override the downloaded value.
• If using claim information, the ‘Statement Covers Period’ is not synonymous with the ‘Admission Date’ and should not be used to abstract this data element. These are two distinctly different identifiers:
  • The Admission Date is purely the date the patient was admitted as an inpatient to the facility.
  • The Statement Covers Period (“From” and “Through” dates) identifies the span of service dates included in a particular claim. The “From” Date is the earliest date of service on the claim.
• For patients who are admitted to Observation status and subsequently admitted to acute inpatient care, abstract the date that the determination was made to admit to acute inpatient care and the order was written. Do not abstract the date that the patient was admitted to Observation.
  • Example:
  • Medical record documentation reflects that the patient was admitted to observation on 04-05-20xx. On 04-06-20xx the physician writes an order to admit to acute inpatient effective 04-05-20xx. The Admission Date would be abstracted as 04-06-20xx; the date the determination was made to admit to acute inpatient care and the order was written.
• The admission date should not be abstracted from the earliest admission order without regards to substantiating documentation. If documentation suggests that the earliest admission order does not reflect the date the patient was admitted to inpatient care, this date should not be used.
  Example:
  Preoperative Orders are dated as 04-06-20xx with an order to admit to Inpatient. Postoperative Orders, dated 05-01-20xx, state to admit to acute inpatient. All other documentation supports that the patient presented to the hospital for surgery on 05-01-20xx. The admission date would be abstracted as 05-01-20xx.
• If there are multiple inpatient orders, use the order that most accurately reflects the date that the patient was admitted.
• For newborns that are born within this hospital, the admission date would be the date the baby was born.
• For inpatient strokes, enter the actual hospital admit date and not the date of stroke symptom discovery. Note this is not from the definition from Specifications Manual for National Hospital Inpatient Quality Measures. 

Suggested Data Sources:

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

ONLY ALLOWABLE SOURCES

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

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

Inclusion Guidelines for Abstraction: None

Exclusion Guidelines for Abstraction:

• Admit to observation
• Arrival date

Summary of Changes

OPTIONAL: Not Admitted?

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

• 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:

• 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
• Discharged from observation status without an inpatient admission
• Other

Notes for Abstraction:

• Transferred from your ED to another acute care hospital: Patient was evaluated in the ED and subsequently transferred to another acute care hospital.
• This field will enable 2 fields for the referring hospital to indicate where the patient is being transferred and the reason for transfering the patient from your hospital
• Additionally, if Reason Not Admitted = "Transferred from your ED to another acute care hospital" is selected, the field will auto-populate the field, For patients discharged on or after 04/01/2011: What is the patient's discharge disposition on the day of discharge? = 4 Acute Care Facilities.
• Discharged directly from ED to home or other location that is not an acute care hospital: Patient was evaluated in the ED and discharged directly from the ED to home or other location not defined elsewhere in this list. Excludes patients who were transferred to another acute care hospital, patients that leave from the ED against medical advice (AMA), and patients discharged from the ED who qualify as observation status.
• Left from ED AMA: Patient was evaluated in the ED and left directly from the ED against medical advice (AMA).
• Died in ED: Patient died after being evaluated in the ED.
• Discharged from observation status without an inpatient admission: Patient was evaluated in the ED and discharged from observation status without a qualifying inpatient admission.
  • Only select "Discharge from observation status without an inpatient admission" if the patient was discharged from the hospital as an observation stay (and was never admitted as an inpatient stay), regardless of the physical location or billing status of the patient during their treatment. Typically, these patients are found in the ED/observation treatment unit, holding units, or in observation status beds in the inpatient area.
  • Observation status should be determined based upon the patient’s hospital stay and the intent of the medical team, and not based upon billing status or physical location of the patient. For example, if the medical team documents that the patient should be admitted as an inpatient, but the claim is later denied as inpatient stay (and is instead reimbursed at observation level) you would still enter this patient as an inpatient as the intent of the medical team was for this patient to be admitted as an inpatient stay. In this case, select "No, admitted to inpatient" for the previous "Not Admitted?" data element.
• Other: Patient was not admitted as an inpatient but discharge disposition from the ED is not defined elsewhere in this list.

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:

• Discharge treatment
• Other lifestyle interventions
• Stroke education
• Stroke rehabilitation
• Discharge checklist.

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:

• Admission Data
• Transfer Data
• ER notes
• Discharge Summary

Select reason(s) for why patient transferred:

• Evaluation for IV tPA up to 4.5 hours: Select this option when patient transferred to another hospital within 4.5 hours of time last known well and patient has not receive IV tPA.
• Post Management of IV tPA (e.g. drip and ship): Patient received IV tPA at the current hospital (referring hospital_ and is being transferred to a higher-level facility (e.g. PSC, CSC) for acute therapy.
• Evaluatio for endovascular thrombectomy: Patient is being evaluated for EVT.
• Advanced stroke care (e.g., Neurocritical care, surgical or other time critical therapy): Reasons may include the folllowing: severe deficits, large-volume infarcts with the potential for significant cerebral edema, significant comorbidities, blood pressure that is difficult to control, or prior intravenous and intra-arterial recanalization interventions.
• Patient/family request: Transfer of patient per family/patient request. Includes administrative reason, such as insurance coverage/no coverage
• Other advanced care (not stroke related): Management of an emergent condition that is not stroke related (e.g. trauma).
• Not documented: Reason for transferring is not documented in the patient's medical record and/or reason for transfer is unknown.

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

Date

MM = Month (01-12)

DD = Day (0-31)

YYYY = Year (2012-Current Year)

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

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:

• This should be the same as the discharge date/time field on the Admin tab (same tab)

• The discharge date/time is the time the ambulance left the hospital with the patient.

Summary of Changes

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

• 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.”

Sources of Data:

• UB-04, Field Number 6

• Discharge Summary

• Face Sheet

• Nursing Discharge Notes

• Physician Notes

Summary of Changes

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

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

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

Allowable Values:

• Yes = There is a reason for delay in transfer documented in the medical record.
• No = There is no documentation in the medical record specific to a delay in transfer of the patient to a referral facility.

Notes for Abstraction:

• Reason for delay in transfer must be documented in the medical record by a physician/ANP/PA.

Summary of Changes

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

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

Allowable Values:

• 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 reperfusion
• 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 measure population

Notes for Abstraction:

• Reason for delay in transfer must be documented in the medical record by a physician/ANP/PA.
• Social/Religious means that the patient and/or family refused treatment due to their cultural or religious beliefs. As patients do have the right to change their treatment decisions, this choice should be selected if there is documentation that treatment with IV alteplase was initially refused due to any social or religious reason. Example: Patient wishes to consult clergy prior to deciding whether or not he wishes to receive treatment. Clergy takes 30 minutes to arrive. After speaking with clergy, the patient decides to proceed with treatment with IV alteplase. Treatment is provided once the patient consents (now 75 minutes after arrival).
• Initial refusal should be selected if there is documentation that the patient and/or family initially refused treatment with IV rt-PA for any reason other than a social/religious reason.
• For patients that cannot participate in shared decision making or provide consent, select "Initial Refusal" if there is documentation that there was a delay in transfer due to reasonable attempts to contact a proxy decision maker to obtain consent.
• "Care-team unable to determine eligibility" means that the diagnosis of stroke was made but that eligibility for thrombolytic therapy or transfer could not be established or verified by the clinician. Examples may include:
• The time of onset could not be clearly established at the time of patient assessment in the ED or time of Last Known Well is unknown
• Timing of a recent procedure or surgery could not be definitively established.
• A lack of an accurate history or concern about the presence of a preexisting medical condition raises concern about eligibility for IV thrombolytic therapy.
• Patients who have experienced multiple episodes of transient neurologic function, or TIAs, which have fully resolved clinically, but imaging or other features of the history make it uncertain as to when the stroke actually started.

Summary of Changes

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

Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

Data Element Name: Discharge Disposition

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

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

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

Format

Length: 1
Type: Alphanumeric
Occurs: 1

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

Notes for Abstraction:

• 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-04

Inclusion Guidelines for Abstraction:
Home (Value 1):
• Assisted Living Facilities (ALFs) – Includes ALFs and assisted living care at nursing home, intermediate care, and skilled nursing facilities
• Court/Law Enforcement – includes detention 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 Hospitalization

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

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

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

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

Exclusion Guidelines for Abstraction:
None

Summary of Changes

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

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

• 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.

Summary of Changes

Clinical codes

REQUIRED FOR TJC, COVERDELL & COMPREHENSIVE (for discharges on or before 9/30/2015): ICD-9-CM Principal Diagnosis Code

Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

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

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

Notes for Abstraction:

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

Suggested Data Sources:

• Discharge summary
• Face sheet
• UB-04

Inclusion Guidelines for Abstraction: None

Exclusion Guidelines for Abstraction: None

Summary of Changes

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

Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

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

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

Notes for Abstraction:
None

Suggested Data Sources:

• Discharge summary
• Face sheet
• UB-04

Inclusion Guidelines for Abstraction: None

Exclusion Guidelines for Abstraction: None

Summary of Changes

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

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

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

Notes for Abstraction:
None

Suggested Data Sources:

• Discharge summary
• Face sheet
• UB-04

Inclusion Guidelines for Abstraction: None

Exclusion Guidelines for Abstraction: None

Summary of Changes

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

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

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

Notes for Abstraction:
None

Suggested Data Sources:

• Discharge summary
• Face sheet
• UB-04

Inclusion Guidelines for Abstraction: None

Exclusion Guidelines for Abstraction: None

Summary of Changes

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

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

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

Notes for Abstraction:
None

Suggested Data Sources:

• Discharge summary
• Face sheet
• UB-04

Inclusion Guidelines for Abstraction: None

Exclusion Guidelines for Abstraction: None

Summary of Changes

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

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

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

Notes for Abstraction:
None

Suggested Data Sources:

• Discharge summary
• Face sheet
• UB-04

Inclusion Guidelines for Abstraction:None

Exclusion Guidelines for Abstraction: None

Summary of Changes

No ICD-10-PCS Procedure Code Documented

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

Notes for Abstraction:

• 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

Summary of Changes

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

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

• 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

Summary of Changes

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

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

• 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

Summary of Changes

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

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

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

Collected For: CSTK-01, CSTK-03

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

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

Format

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

Allowable Values:

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

Notes for Abstraction:

• 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.

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

Exclusion: None

Summary of Changes

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

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

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

Collected For: CSTK-01, CSTK-03

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

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

Format

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

Allowable Values:

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

Notes for Abstraction:

• 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.

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

Exclusion: None

Summary of Changes

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

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

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

Suggested Data Sources:

• 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

Summary of Changes

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

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

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

Notes for Abstraction:
None

Suggested Data Sources:

• Discharge summary
• Face sheet
• UB-04

Inclusion Guidelines for Abstraction: None

Exclusion Guidelines for Abstraction: None

Summary of Changes

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

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

• 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

Summary of Changes

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

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

• 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

Summary of Changes

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

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

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

Collected For: CSTK-01, CSTK-03

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

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

Format

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

Allowable Values:

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

Notes for Abstraction:

• 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.

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

Exclusion: None

Summary of Changes

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

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

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

Collected For: CSTK-01, CSTK-03

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

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

Format

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

Allowable Values:

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

Notes for Abstraction:

• 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.

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

Exclusion: None

Summary of Changes

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

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

Data Element Name: Admitting Diagnosis

Collected For: CSTK-04

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

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

Format

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

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

Notes for Abstraction:

• 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

Summary of Changes

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

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

Data Element Name: Admitting Diagnosis

Collected For: CSTK-04

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

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

Format

Length: 3-7 (without decimal point or dot; upper or lower case)
Type: Character
Occurs: 1

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

Notes for Abstraction:

• 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

Summary of Changes

Discharge Diagnoses

• ICD-9-CM discharge diagnosis related to stroke
• No Stroke or TIA related ICD-9-CM code present
• ICD-10-CM discharge diagnosis related to stroke
• No Stroke or TIA related ICD-10-CM code present

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

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

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

Summary of Changes

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

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

Summary of Changes

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

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

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

Summary of Changes

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

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

Summary of Changes

Admission Tab:

Arrival and Admission Information

• During this hospital stay, was the patient enrolled in a clinical trial in which patients with the same condition as the measure set were being studied?
• Was this patient admitted for the sole purpose of performance of elective carotid intervention?
• Patient location when stroke symptoms discovered
• How patient arrived at your hospital
• Referring hospital discharge date/time
• Specify the referring hospital name
• Referring hospital arrival date/time
• Select reason(s) for why patient transferred:
• Was the patient an ED patient at the facility?
• Was the patient a direct admission to the hospital?
• Where patient first received care at your hospital
• Advanced notification by EMS or Mobile Stroke Unit?
• Initial Admitting Service
• In which settings were care delivered? Select all that apply.
• If the patient was not cared for in a dedicated stroke unit, was a formal inpatient consultation from a stroke expert obtained?
• Physician/Provider NPI

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

Type: Alphanumeric

Occurs: 1

Allowable Values:

• Y (Yes) There is documentation that during this hospital stay the patient was enrolled in a clinical trial in which patients with the same condition as the measure set were being studied (i.e. STK, VTE)
• N (No) There is no documentation that during this hospital stay the patient was enrolled in a clinical trial in which patients with the same condition as the measure set were being studied (i.e.STK, VTE), or unable to determine from medical record documentation

Notes for Abstraction:

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

In the following situations, select "No":

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

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

Suggested Data Sources:

Only acceptable data sources: Signed consent form for clinical trial

Inclusion Guidelines for Abstraction: None

Summary of Changes

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

Element definition from Specifications Manual for National Hospital Inpatient Quality Measures

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

• 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-up

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

 

Summary of Changes

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

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

• 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

Summary of Changes

REQIRED: How patient arrived at your hospital

• EMS from home/scene
• Mobile Stroke Unit
• Private transportation/taxi/other from home/scene
• Transfer from other hospital/free-standing ED
• ND or unknown

Notes for Abstraction:

• Select "EMS from home/scene" whenever the patient was brought to your hospital from home/scene by EMS, whether by ground EMS or Air EMS. Private ambulance transport would be included in this EMS category.
• If a patient is transported by EMS from an Urgent Care Facility, or private physician office, choose "EMS from home/scene."
• If a patient is transferred to your facility via Mobile Stroke Unit, select "Mobile Stroke Unit". NOTE: Mobile Stroke Units are NOT currently common in the US. In the rare instance your region has a Mobile Stroke Unit and the patient arrives via that unit, you may select this option. A Mobile Stroke Unit is a transport unit capable of diagnosing and treating acute strokes in the field. It contains highly specialized staff, imaging capabilities (CT scanner), mobile lab and the ability to administer IV alteplase.
• If a patient is transferred from another hospital or satellite/free-standing ED, choose “Transfer from other hospital/free-standing ED”.
• If the patient arrived via a mobile stroke unit, select “Mobile Stroke Unit.”
• 'Private transportation/taxi/other from home or scene includes cab, bus, car, walk-in, Uber/Lyft etc.
• If the medical record or the EMS run sheet does not specify how patient arrived at your hospital, select “ND or Unknown.”

Referring hospital discharge date/time

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

• 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

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

• Complete this information only if you are the hospital that received the patient.
• Enter the date and time the patient was discharged from the referring center.
• If the discharge date/time for the referring hospital is not in the patient's transfer notes/medical record, select the "Hospital Not Documented" checkbox.

• Consultation notes
• Emergency department record
• Transfer notes
• History and physical

Specify the referring hospital name

• Dropdown list with hospital names based on American Hospital Association (AHA) List
• Hospital not on the List
• Hospital not documented

• Select from the dropdown menu, the hospital the patient was transferred to during this episode of care.

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

• Hospital not on the List: Select this option if the hospital name is not displayed in the current AHA ID lookup tool.


• Hospital not documented: Select this option if the hospital the patient was transferred does not appear in the medical record or is unknown.

• Consultation notes
• Emergency department record
• Transfer notes
• History and physical

Referring hospital arrival date/time

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

• 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

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

• Enter the date and time the patient arrived at your hospital
• If the arrival date/time for the patient arrived to your hospital is not in the patient's transfer notes/medical records, select "Unknown."

• EMS Run Sheet
• Emergency department record
• Transfer notes

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:

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

• Evaluation for IV tPA up to 4.5 hours: Select this option when patient transferred to another hospital within 4.5 hours of time last known well and patient has not received IV tPA.
• Post Management of IV tPA (e.g. drip and ship): Patient received IV tPA at the current hospital (referring hospital) and is being transferred to a higher-level facility (e.g. PSC, CSC) for acute therapy.
• Evaluation for endovascular thrombectomy: Patient is being evaluated for EVT.
• Advanced stroke care (e.g., Neurocritical care, surgical or other time critical therapy): Reasons may include the following: severe deficits, large-volume infarcts with the potential for significant cerebral edema, significant comorbidities, blood pressure that is difficult to control, or prior to intravenous and intra-arterial recanalization interventions.
• Patient/family request: Transfer of patient per family/patient request. Includes administrative reason, such as insurance coverage/no coverage, lack of bed capacity.
• Other advanced care (not stroke related): Management of an emergent condition that is not stroke related (e.g. trauma).
• Not documented: Reason for transferring is not documented in the patient's medical record and/or reason for transfer is unknown.

Summary of Changes

Was the patient an ED patient at the facility?