Chester Clinic

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Stroke Certification
Performance Measures and Indicators A Program of the American Osteopathic Association
142 East Ontario Street Chicago, IL 60611-2864 PERFORMANCE MEASURES AND INDICATORS
This section of the manual contains information related to the quality performance of Stroke Centers. Brain Attack Coalition Definitions Recognition of Superior Performance: this includes all of the performance indicators that facilities are required to submit to HFAP. What makes this distinction unique is that a facility who demonstrates 95% compliance in all indicators for a period of three consecutive quarters will be recognized as demonstrating superior performance in the care of the stroke patient. They will be awarded a plaque and a certificate that they may display as they choose. They will also be recognized on the HFAP website. Performance Measure Indicator Definitions: this includes specific definitions for each performance measure that is required to be submitted to HFAP. Seven of these measures are identical to the AHA Get with the Guidelines Performance Measures, which HFAP has adopted. Data Collection Tool: this tool is being provided to HFAP Stroke Centers to assist in their data collection activities. The use of this tool is not mandatory. Data Submission Tool: this tool is being provided to HFAP certified Stroke Centers to submit their stroke data. The intent is to provide consistency in the tracking and trending of stroke data. All required data and performance indicators must be submitted electronically, by emailing facility results to The required quarterly dates for submission are: 1st quarter-April 30 2nd quarter- July 31 3rd quarter-September 30 4th quarter-January 31 2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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PERFORMANCE MEASURES AND INDICATORS
Definitions Established by the Brain Attack Coalition (BAC):
1. Brain Attack Coalition (BAC) - The Brain Attack Coalition is a multidisciplinary organization that includes most major
medical organizations involved with stroke care that assembled to establish guidance about the formation and operation of stroke centers. 2. Primary Stroke Center (PSC) - According to the Brain Attack Coalition, the Primary Stroke Center "stabilizes and provides emergency care for patients with acute stroke. Such centers would then either transfer the patient to a comprehensive stroke center or could admit the patient and provide further care depending on the patient's needs and the center's capabilities." (JAMA, 2000) "Their emergency departments should be able to offer approved therapies to appropriately selected patients whether the stroke is ischemic or hemorrhagic." 3. Comprehensive Stroke Center (CSC): a. According to the Brain Attack Coalition, "A Comprehensive Stroke Center "would provide complete care to patients experiencing the most complex strokes that require specialized testing and other interventions. Such comprehensive stroke centers typically would include tertiary care medical centers and hospitals with the infrastructure and personnel necessary to perform highly technical procedures and provide all needed levels of care." Source: Alberts, Mark J., et al., "Recommendations for the Establishment of Comprehensive Stroke Centers," JAMA, June 21, 2000, Vol. 283, No. 23, 3102-3109. b. In 2005, the Brain Attack Coalition further defined the Comprehensive Stroke Center as "A facility or system with the necessary personnel, infrastructure, expertise, and programs to diagnose and treat stroke patients who require a high intensity of medical and surgical care, specialized tests, or interventional therapies. The types of patients who might use and benefit from a CSC include (but are not limited to) patients with large ischemic strokes or hemorrhagic strokes, those with strokes from unusual etiologies or requiring specialized testing or therapies, or those requiring multispecialty management. Additional functions of a CSC would be to act as a resource center for other facilities in their region, such as PSCs. This might include providing expertise about managing particular cases, offering guidance for triage of patients, making diagnostic tests or treatments available to patients treated initially at a PSC, and being an educational resource for other hospitals and health care professionals in a city or region." Source: Alberts, MJ, et al, "Recommendations for Comprehensive Stroke Centers - A Consensus Statement from the Brain Attack Coalition," Stroke, July 2005, 1597-1618. 2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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PERFORMANCE MEASURES AND INDICATORS
The following performance measures are to be collected and submitted quarterly to HFAP. Performance Measures and Indicators
Threshold Stroke Ready
Stroke team arrival Laboratory studies Neuroimaging studies Neurosurgical services tPA administration (0-3 hr) Antithrombotic therapy Antithrombotic therapy @ discharge Anticoagulant therapy @ discharge SM-10 Statin @ discharge
SM-11 Smoking cessation education
SM-12 Dysphagia screening
SM-13 Physical rehabilitation evaluation
SM-14 Discharge physical rehabilitation referral
SM-15 Door-to-Needle time
SM-16 NIHSS scores for ischemic stroke or TIA
SM-17 Initial severity measures for SAH, ICH & AVM
SM-18 Clipping/coiling w/in 48hrs
SM-19 Nimodipine Treatment w/in 24hrs to <21days
SM-20 INR reversal with procoagulant preparation
SM-21 Diagnostic neuroangiography within 24 hrs
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Stroke Team Arrival
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Arrival within 15 minutes / All patients exhibiting or presenting with clinical stroke symptoms. Numerator
Patients 18 years of age and older, with the stroke team responding to bedside within 15 minutes of arrival in ED. Inclusion
Inpatients 18 years of age and older, where the stroke team responded to bedside within 15 minutes of onset of symptomology. Denominator
Patients 18 years of age and older, presenting to the ED with clinical stroke symptoms. Inclusion
Inpatients 18 years of age and older, developing clinical stroke symptoms during hospitalization. Exclusion
Patients under the age of 18 Cancellation of stroke code Data Source
ED log chief complaints, ED recorded time of patient presentation; ED recorded time of stroke team arrival, discharge diagnoses, documented onset of symptomology of inpatients. Definitions
Arrival in ED: The time in which the patient, experiencing symptoms of acute stroke arrives in the Emergency
Department
Symptoms of acute stroke: Sudden severe headache; sudden loss of vision in one or both eyes; sudden weakness in
an arm, leg or face; sudden confusion, trouble speaking, or understanding; and sudden trouble walking, dizziness, or
loss of balance or coordination
Response Time: The time between presentation of patient to ED with stroke symptoms and the arrival of the stroke
team to the bedside; or the time between the inpatient onset of symptoms to the time of the stroke team arrival to the
bedside
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Laboratory Studies
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Number of patients with labs turnaround time (TAT) within 45 minutes of arrival / All patients exhibiting or presenting with stroke symptoms. Numerator
Patients 18 years of age and older, where lab testing was drawn and resulted within 45 minutes of arrival in ED. Inclusion
Inpatients 18 years of age and older, where the lab testing was drawn and resulted within 45 minutes of onset of symptomology. Denominator
Patients 18 years of age and older, presenting to the ED with clinical stroke symptoms. Inclusion
Inpatients 18 years of age and older, developing clinical stroke symptoms during hospitalization. Exclusion
Patients under the age of 18. Laboratory results indicating cell lysis / other erroneous results. Patients who expired. Patients who left the emergency department against medical advice or discontinued care. Data Source
ED log chief complaints, ED recorded time of patient presentation, ED recorded time of stroke team arrival, discharge diagnoses, documented onset of symptomology of inpatients; laboratory orders; laboratory results Definitions
TAT: Turnaround time of lab results should be within 45 minutes of arrival in ED or onset of symptomology on the in-
patients
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Neuroimaging Studies
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Number of patients with neuro-imaging turnaround time (TAT) within 45 minutes of arrival / All patients exhibiting or presenting with stroke symptoms. Numerator
Patients 18 years of age and older, where neuro-imaging was completed within 45 minutes of arrival in ED. Inclusion
Inpatients 18 years of age and older, where neuro-imaging was completed within 45 minutes of onset of symptomology. Denominator
Patients 18 years of age and older, presenting to the ED with clinical stroke symptoms. Inclusion
Inpatients 18 years of age and older, developing clinical stroke symptoms during hospitalization. Exclusion
Patients under the age of 18. Patients who expired. Patients who left the emergency department against medical advice or discontinued care. Data Source
ED log chief complaints, ED recorded time of patient presentation, ED recorded time of stroke team arrival, discharge diagnoses, documented onset of symptomology of inpatients; neuro-imaging orders; neuro-imaging results Definitions
TAT: Turnaround time of neuro-imaging results should be within 45 minutes of arrival in ED or onset of
symptomology on the in-patients
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Neurosurgical Services
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Number of patients receiving neuro-surgical services within 2 hours of need / all patients diagnosed with hemorrhagic stroke. Numerator
Patients 18 years of age and older identified on CT as experiencing a hemorrhagic stroke, Inclusion
Neuro-surgical services available within 2 hours of identified need for patients 18 years of age and older. Denominator
Patients 18 years of age and older identified on CT as experiencing a hemorrhagic stroke. Inclusion
Exclusion
Patients with clinical diagnosis of TIA / ischemic stroke. Data Source
ED log chief complaints, ED recorded time of patient presentation, ED recorded time of stroke team arrival, discharge diagnoses, documented onset of symptomology of inpatients; neuro-imaging orders; neuro-imaging results; consultation orders/notes; time of transfer (if applicable); time to OR (if applicable). Definitions
Diagnosis of Hemorrhagic Stroke: Diagnosis should be made on CT scan or MRI, within 45 minutes of arrival to
ED/onset of symptoms for inpatients
Identified Need: Patient will have a clinical diagnosis of hemorrhagic stroke confirmed by neuro-imaging
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
tPA Administration (0-3 hours)
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Number of patients received tPA within 3 hours / number of eligible patients. Numerator
All patients that received initiation of tPA within 3 hours. Inclusion
Denominator
All patients presenting with acute ischemic stroke symptomology, eligible to receive tPA. Inclusion
Exclusion
Patients who left Against Medical Advice. Patients transferred to another facility. Patients presenting with acute ischemic stroke symptoms which exhibit contraindications to administration of tPA. Data Source
ED log chief complaints, ED recorded time of symptom on-set; ED recorded time of patient presentation, ED recorded time of stroke team arrival, discharge diagnoses, documented onset of symptomology of inpatients; neuro-imaging results; Documentation of contraindications to administration; documented time of initiation of tPA. Definitions
tPA: Tissue Plasminogen Activator
Contraindications (C) and Warnings (W):
Evidence of intracranial hemorrhage on pretreatment CT.C Only minor or rapidly improving stroke symptoms.W Clinical presentation suggestive of subarachnoid hemorrhage, even with normal CT.C Active internal bleeding.C 2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
tPA Administration (0-3 hours) continued…
Definitions
Known bleeding diathesis, including but not limited to:
 Platelet count < 100,000/mm.  Patient has received heparin within 48 hours and has an elevated aPTT (greater than upper limit of normal for  Current use of oral anticoagulants (e.g., warfarin sodium) or recent use with an elevated Prothrombin time > 15 Patient has had major surgery or serious trauma excluding head trauma in the previous 14 days.W Within 3 months any intracranial surgery, serious head trauma, or previous stroke.C History of gastrointestinal or urinary tract hemorrhage within 21 days.W Recent arterial puncture at a noncompressible site.W Recent lumbar puncture.W On repeated measurements, systolic blood pressure greater than 185 mm Hg or diastolic blood pressure greater than 110 mm Hg at the time treatment is to begin, and patient requires aggressive treatment to reduce blood pressure to within these limits.C History of intracranial hemorrhage.C Abnormal blood glucose ( < 50 or > 400 mg/dL).W Post myocardial infarction pericarditis.W Patient was observed to have seizure at the same time the onset of stroke symptoms were observed.W Known arteriovenous malformation, or aneurysm.C Resources: Brain Attack Coalition, American College of Emergency Physicians
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Thrombotic Therapy
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Number of Patients received 1st dose antithrombotic within 48 hours hospital arrival / Total number eligible patients. Numerator
All eligible patients who received the 1st dose of antithrombotic with 48 hours of presentation to the hospital. Inclusion
Denominator
All eligible patients presenting with acute ischemic stroke symptoms. Inclusion
Exclusion
Patients who left Against Medical Advice. Patients transferred to another facility. Patients with contraindications to antithrombotic therapy. Patients under the age of 18. Data Source
ED log chief complaints; ED recorded time of patient presentation, ED recorded time of stroke team arrival, discharge diagnoses, documented onset of symptomology of inpatients; neuro-imaging results; Documentation of contraindications to administration (if applicable); Documented time of administration of 1st dose of antithrombotic. Definitions
Eligible Patients: Those patients age 18 & older for which antithrombotic therapy is deemed to be indicated
Antithrombotic Therapy: Group of medications which would include anti-platelets and anticoagulants used in the
treatment of ischemic stroke
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Antithrombotic Therapy at Discharge
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Number of patients given prescription for antithrombotic at time of discharge / Number patients eligible for antithrombotic therapy at discharge. Numerator
All eligible patients who received prescription for antithrombotic at time of discharge. Inclusion
Denominator
All eligible patients presenting with acute ischemic stroke symptoms. Inclusion
Exclusion
Patients who left Against Medical Advice. Patients transferred to another facility. Patients with contraindications to antithrombotic therapy. Patients under the age of 18. Data Source
ED log chief complaints; ED recorded time of patient presentation, ED recorded time of stroke team arrival, discharge diagnoses, documented onset of symptomology of inpatients; Neuro-imaging results; Documentation of contraindications to administration (if applicable); Documentation that prescription for antithrombotic given at discharge. Definitions
Eligible Patients: Those patients age 18 & older with an acute ischemic stroke or TIA diagnosis for which
antithrombotic therapy is deemed to be indicated
Antithrombotic Therapy: group of medications which would include anti-platelets and anticoagulants
TIA: Transient Ischemic Attack
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Anticoagulant Therapy at Discharge
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Number of eligible patients with atrial fibrillation given prescription for anticoagulant at time of discharge / Number patients eligible for anticoagulant therapy at discharge. Numerator
All eligible patients who received prescription for anticoagulant at time of discharge. Inclusion
Denominator
All eligible patients with atrial fibrillation. Inclusion
Exclusion
Patients who left Against Medical Advice. Patients transferred to another facility. Patients with contraindications to anticoagulant therapy. Patients under the age of 18. Data Source
ED log chief complaints; ED recorded time of patient presentation, ED recorded time of stroke team arrival, discharge diagnoses, documented onset of symptomology of inpatients; Neuro-imaging results; Documentation of contraindications to administration (if applicable); Documentation that prescription for anticoagulant given at discharge. Definitions
Eligible Patients: Those patients age 18 & older with an acute ischemic stroke or TIA diagnosis for which
antithrombotic therapy is deemed to be indicated
TIA: Transient Ischemic Attack
Atrial Fibrillation: Clinical diagnosis
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
VTE Prophylaxis
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Number of eligible patients received VTE prophylaxis within 48 hours of hospital arrival / Number patients with ischemic stroke determined to be at risk for VTE. Numerator
All eligible patients who received VTE prophylaxis within 48 hrs of arrival to hospital. Inclusion
Denominator
All eligible patients determined to be at risk for VTE. Inclusion
Exclusion
Patients who left Against Medical Advice. Patients transferred to another facility. Patients with contraindications to VTE prophylaxis. Patients under the age of 18. Data Source
ED log chief complaints; ED recorded time of patient presentation, ED recorded time of stroke team arrival, discharge diagnoses, documented onset of symptomology of inpatients; Neuro-imaging results; documentation of contraindications to administration (if applicable); Documentation that VTE prophylaxis was initiated within 48 hrs of arrival to hospital. Definitions
Eligible Patients: Those patients age 18 & older with an acute ischemic stroke or TIA diagnosis determined to be at
risk for VTE for which prophylaxis is deemed to be indicated
TIA: Transient Ischemic Attack
VTE Prophylaxis: treatments given to thwart the development of VTE, to include anticoagulant medications, sequential
compression stockings, and early mobilization
VTE: Venous Thromboembolism
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Statin at Discharge
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Number of eligible patients received prescription for statins at discharge / Number patients with ischemic stroke or TIA discharged. Numerator
All eligible patients who received prescription for statin at the time of discharge. Inclusion
Denominator
All discharged patients with ischemic stroke or TIA. Inclusion
Exclusion
Patients who left Against Medical Advice. Patients transferred to another facility. Patients with allergies to statin medications. Patients under the age of 18. Data Source
ED log chief complaints; ED recorded time of patient presentation, ED recorded time of stroke team arrival, discharge diagnoses, documented onset of symptomology of inpatients; Neuro-imaging results; Documentation of contraindications to administration (if applicable); Documentation that statin prescription was given at time of discharge. Definitions
Eligible Patients: Those patients age 18 & older with an acute ischemic stroke or TIA diagnosis
TIA: Transient Ischemic Attack
Statin: Lipid-lowering Therapy
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Smoking Cessation Education
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Number of eligible patients received smoking cessation advice prior to discharge / Number patients with ischemic stroke, hemorrhagic stroke or TIA who use tobacco. Numerator
All eligible patients who received smoking cessation advice prior to discharge. Inclusion
Denominator
All discharged patients with ischemic stroke, hemorrhagic stroke or TIA who use tobacco products. Inclusion
Exclusion
Patients who left Against Medical Advice. Patients transferred to another facility. Patients who do not use tobacco. Patients under the age of 18. Data Source
ED log chief complaints; ED recorded time of patient presentation, ED recorded time of stroke team arrival, discharge diagnoses, documented onset of symptomology of inpatients; Neuro-imaging results; Documentation of contraindications to administration (if applicable); Documentation that smoking cessation advice has been provided prior to discharge. Definitions
Eligible Patients: Those patients age 18 & older with an acute ischemic stroke, hemorrhagic stroke or TIA diagnosis
with a history of current tobacco use.
TIA: Transient Ischemic Attack
Tobacco Use: History of smoking cigarettes, cigars, and pipes
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Dysphagia Screening
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Number of eligible patients received dysphagia screen prior to receiving anything by mouth / Number patients with acute stroke symptoms who received anything by mouth. Numerator
All eligible patients who received dysphagia screen and have received something by mouth. Inclusion
Denominator
All eligible patients who received anything by mouth. Inclusion
Exclusion
Patients who left AMA. Patients transferred to another facility. Patients who did not receive anything by mouth. Patients under the age of 18. Data Source
ED log chief complaints; ED recorded time of patient presentation, ED recorded time of stroke team arrival, discharge diagnoses, documented onset of symptomology of inpatients; Neuro-imaging results; Documentation that dysphagia screen completed prior to taking anything by mouth. Definitions
Eligible Patients: Those patients age 18 & older with acute stroke symptoms.
TIA: Transient Ischemic Attack
Dysphagia Screen: Simple, valid bedside testing protocol (may be performed by RN).
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Physical Rehabilitation Evaluation
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Number of eligible patients receiving initial physical rehab evaluation within 48 hrs of hospital arrival / Number patients with ischemic or hemorrhagic stroke. Numerator
All eligible patients who received initial physical rehabilitation evaluation within 48 hrs. Inclusion
Denominator
All eligible patients. Inclusion
Exclusion
Patients who left AMA. Patients transferred to another facility. Diagnosis of TIA. Patients under the age of 18. Data Source
ED log chief complaints; ED recorded time of patient presentation, ED recorded time of stroke team arrival, discharge diagnoses, documented onset of symptomology of inpatients; Neuro-imaging results; Documentation that initial physical rehab evaluation completed within 48 hrs. Definitions
Eligible Patients: Those patients age 18 & older with acute ischemic or hemorrhagic stroke.
Initial Physical Rehab: PT, OT, ST
TIA: Transient Ischemic Attack
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Discharge Physical Rehabilitation Referral
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Number of eligible patients receiving appropriate physical rehab referral prior to discharge / Number discharge patients with ischemic or hemorrhagic stroke. Numerator
All eligible patients who received initial physical rehabilitation referral prior to discharge. Inclusion
Denominator
All eligible patients discharged. Inclusion
Exclusion
Patients who left AMA. Patients transferred to another facility. Diagnosis of TIA. Patients under the age of 18. Data Source
ED log chief complaints; ED recorded time of patient presentation, ED recorded time of stroke team arrival, discharge diagnoses, documented onset of symptomology of inpatients; Neuro-imaging results; Documentation that initial physical rehab referral completed prior to discharge. Definitions
Eligible Patients: Those patients age 18 & older with acute ischemic or hemorrhagic stroke
Initial Physical Rehab: PT, OT, ST
TIA: Transient Ischemic Attack
Physical Rehab Referral: PT, OT, ST - to continue post discharge as needed
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Door-to-Needle time
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Acute ischemic stroke patients age 18 years and older receiving intravenous tissue plasminogen activator (tPA) therapy during the hospital stay and having a time from hospital arrival to initiation of thrombolytic therapy administration (door-to-needle) of 60 minutes or less. Numerator
Acute ischemic stroke patients aged 18 years or older receiving intravenous tissue plasminogen activator (tPA) therapy during Inclusion
the hospital stay and having a time from hospital arrival to initiation of thrombolytic therapy administration (door-to-needle time) of 60 minutes or less. Denominator
All acute ischemic stroke patients who received intravenous thrombolytic therapy within 4.5 hours of symptom onset. Inclusion
Exclusion
Patients less than 18 years of age Patient stroke occurred while in hospital Patients received in transfer from the inpatient, or outpatient of another facility Patients who did not receive thrombolytic therapy within 60 minutes and had a reason for delay documented by a physician/advanced practice nurse/physician assistant as the cause for delay; social, religious, initial refusal, hypertension requiring aggressive control with intravenous medications, inability to confirm patients eligibility, or further diagnostic evaluation to confirm stroke for patients with hypoglycemia (blood glucose <50); seizures, or major metabolic disorders, or management of concomitant emergent/acute conditions such as cardiopulmonary arrest, respiratory failure requiring intubation), or investigational or experimental protocol for thrombolysis. Data Source
Discharges with principal diagnosis code for Acute Ischemic Stroke. Definitions
Door-to-needle: time from hospital arrival to administration of intravenous tissue activator (tPA) therapy Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
National Institutes of Health Stroke Scale Score on Arrival
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Percentage of patients who have an ischemic stroke or who have a transient ischemic attack (TIA) with a deficit at the time of the initial admitting note or neurology consultation note for which a National Institutes of Health Stroke Scale (NIHSS) score is documented. Numerator
Number of patients with ischemic stroke or TIA with a deficit at the time of the initial admitting or neurological consultation note Inclusion
for whom an NIHSS is recorded in the first admitting note or in the first neurology consultation notes, whichever comes first, or in a separate earlier note. Patients with acute ischemic stroke treated with tPA or with an acute endovascular procedure must be included in the numerator only if the NIHSS is performed before the start of these treatments. Denominator
All patients who have an ischemic stroke or TIA with a deficit at the time of the initial admitting or neurology consultation note Inclusion
or who undergo intravenous tPA or acute endovascular treatment with complete resolution of their deficit. Patients with a TIA should be included if they still have a deficit at the time of the initial admitting or consultation note. In addition, the NIHSS be performed by a certified examiner. Exclusion
Patients under the age of 18. Patients who expired within one hour of arrival to hospital. Patients admitted for Elective Carotid Intervention. Data Source
Primary diagnosis of Ischemic Stroke or TIA. Definitions
TIA: Transient Ischemic Attack
tPA: tissue plasminogen activator
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Severity Measurement on Arrival
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Percentage of SAH, ICH, and AVM patients for whom initial severity measures are documented. The severity of SAHs must be documented with the Hunt and Hess scale, which incorporates the Glasgow Coma Scale (GCS) and the size and location of the hemorrhage, AVMs should be graded according to the Spetzler-Martin scale. A combined ratio should be calculated as the primary metric. Numerator
The sum of the number of SAH patients for whom the Hunt and Hess scale is documented, the number of ICH patients without Inclusion
an AVM for whom the ICH score is documented, the number of AVM patients with hemorrhage for whom the ICH score and Spetzler-Martin score are documented, and the number of AVM patients without hemorrhage for whom the Spetzler-Martin is documented. For a patient to be counted in the numerator, the Hunt and Hess and GCS scores should be documented in the initial neurological or neurosurgical admitting or consultation note or in a separate earlier note and should be evaluated before the start of any endovascular or surgical procedure. The ICH score and Spetzler-Martin score may be determined later after analysis of imaging. Denominator
Sum of the number of SAH patients, the number of ICH patients without an AVM, and the number of AVM patients. Inclusion
Exclusion
Patients less than 18 years of age. Patients who expired within one hour of arrival at this hospital. Patients with traumatic brain injury (TBI), unruptured arteriovenous malformation (AVM), and non-traumatic subdural hematoma. Data Source
Primary diagnosis of Ischemic Stroke or TIA. Definitions
SAH: Aneurysmal Subarachnoid Hemorrhage
ICH: Ischemic Cerebrovascular Disease
AVM: Arteriovenous Malformations
GCS: Glasgow Coma Scale
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Clipping / Coiling within 48 hours (core measure = 48 hours)
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Median time from admission to start of procedure intended to obliterate a ruptured aneurysm by surgical clipping or endovascular coiling for patients who arrive within 48 hours of the hemorrhage that led directly to admission. Numerator
Patients who are not treated must be excluded from this metric, but the reason they were not treated must be recorded. Times Inclusion
for this metric should be recorded to the nearest hour, in contrast to the measures for acute ischemic stroke, which should be recorded in hours and minutes. Patients with sentinel hemorrhage greater than 48 hours before admission and a second hemorrhage within the 48 hours before admission should be included in this metric. Denominator
Total number of patients with aneurysmal SAH who arrive within 48 hours of hemorrhage and whose ruptured aneurysm is not Inclusion
coiled or clipped within 36 hours of arrival. Exclusion
Patients under the age of 18 years Reasons for not treating may include but are not limited to futility, medical instability, patient or family wishes, and delayed arrival of the patient to the CSC. Data Source
Patients under the age of 18 years Primary diagnosis of aneurysmal SAH Definitions
SAH: Aneurysmal Subarachnoid Hemorrhage
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Nimodipine Treatment within 24 hours to <21 days
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Percentage of patients with documented aneurysmal SAH for whom nimodipine treatment (60 mg every 4 hours or 30 mg every 2 hours) is started within 24 hours of diagnosis and for whom such treatment is continued until 21 days after the hemorrhage or until discharge if they are discharged < 21 days after the SAH. Patients who arrive at a CSC with documented aneurysmal SAH should receive nimodipine within 24 hours of admission. The AHA/ASA "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage" recommend nimodipine to reduce the risk of poor outcomes after aneurysmal SAH. Nimodipine has been approved by the US Food and Drug Administration for "improvement of neurological outcome by reducing the incidence and severity of ischemic deficits in patients with subarachnoid hemorrhage from ruptured intracranial berry aneurysms." Numerator
Patients with documented aneurysmal SAH treated with nimodipine 60 mg every 4 hours (or 30 mg every 2 hours) within 24 Inclusion
hours of diagnosis and who continue this treatment until 21 days after their hemorrhage, or until discharge if they are discharged less than 21 days after the SAH, or until they develop a contraindication to nimodipine. Acceptable contraindications include documentation of intractable hypotension or allergy to nimodipine. Patients whose dose of nimodipine is reduced because of hypotension will be considered to be in compliance with this metric. Denominator
All patients with a diagnosis of aneurysmal SAH who are included in the population that has been or should have been a Inclusion
candidate for Nimodipine treatment. Exclusion
Patients under the age of 18 years Data Source
Patients with primary diagnosis of SAH Definitions
SAH: Aneurysmal Subarachnoid Hemorrhage
Threshold
2013-2014 HFAP Stroke Certification CONFIDENTIAL DOCUMENT
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
INR Reversal
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Median time from arrival to start of treatment to reverse the INR with a procoagulant preparation (e.g., fresh frozen plasma, recombinant factor VIIa, prothrombin complex concentrates) for patients with warfarin-associated ICH and an elevated INR (INR >1.4). Times for this metric should be recorded in minutes. Numerator
ICH stroke patients for whom treatment to reverse the INR with a procoagulant e.g., fresh frozen plasma, recombinant factor Inclusion
VIIa, prothrombin complex concentrates) was initiated within 2 hours (120 minutes) of arrival at this hospital. Denominator
ICH stroke patients with an INR > 1.4. Inclusion
Exclusion
Patients with an elevated INR should be excluded from this metric if a reason is documented for not treating them. Patients less than 18 years of age. Patients with Comfort Measures Only documented on day of or after hospital arrival. Patients enrolled in clinical trials. Patients with procoagulant therapy initiated prior to hospital arrival. Patients who expired within two hours of arrival at this hospital. Data Source
Definitions
ICH: Intracerebral Hemorrhage INR: International Normalized Ratio Threshold
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CLINICAL MEASURES AND PERFORMANCE INDICATORS
Diagnostic Neuroangiography within 24 hours
Measure Type
Applicable to:
Stroke Ready Centers Primary Stroke Centers Comprehensive Stroke Centers Background
Percentage of patients with stroke or death within 24 hours of diagnostic neuroangiography. This metric is limited to patients with atherosclerotic disease to ensure that the metric encompasses a uniform population of patients. Numerator
Patients with death or stroke after diagnostic neuroangiography within 24 hours of the procedure or before discharge, Inclusion
whichever comes first. Denominator
All patients who undergo a diagnostic neuroangiographic procedure. Inclusion
Exclusion
Patients are excluded if they undergo a therapeutic angiographic intervention as part of the same procedure or within the first 24 hours after the diagnostic procedure unless the complication is identified before the therapeutic intervention begins. Strokes or deaths that occur after 24 hours of the diagnostic angiogram. Patients less than 18 years of age. Data Source
Inclusion of only those strokes or deaths that occur within 24 hours of the diagnostic angiogram. (Because of the consensus that diagnostic angiography should be a low-risk procedure, and because the end point should be straightforward to collect, this is a core metric). Definitions
Threshold
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Source: http://www.hfap.org/pdf/5_StrokeMeasures.pdf