stroke core measures 2021

2 0 obj Share sensitive information only on official, secure websites. A hospitals hemorrhagic stroke patient population size is 795 cases during the second quarter. A hospitals ischemic stroke patient population size is 7 cases during March. Include the patient in the Initial Patient Population for the appropriate measures. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 42 cases for the quarter. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this Agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. The reduction of LDL cholesterol, through lifestyle modification and drug therapy when appropriate, is recommended for the prevention of recurrent ischemic stroke, heart attack, and other major vascular events. endobj STK-6 Discharged on Statin Medication12. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only, 2. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. View them by specific areas by clicking here. Especially if you use an EHR vendor right now, youll notice a huge difference. ASR-OP-2c Ischemic Stroke; drip and ship4. Statin drugs are medications used to reduce serum level of lipids such as cholesterol. You, your employees and agents are authorized to use CPT only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. A hospitals hemorrhagic stroke patient population size is 295 cases during March. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size is less than the minimum required quarterly sample size, so 100% of the subpopulation or all 19 cases are sampled. Visit: . Closed on Sundays. Here I have broken it into the inpatient measure set and the outpatient measure set. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> I also included the complete list of measures required for each certification. Find evidence-based sources on preventing infections in clinical settings. Unauthorized use prohibited. CSTK-05 Hemorrhagic Transformation, 1. CSTK-05 Hemorrhagic Transformation, 1. R,A`=N T$gZq,AW@0H#`.K#AJk_~}~Dc7?o=0T,qp{"+&y8N^-9yG-W +~ZY(DA[xvc2EGJv;P.Q12`3'o0f}ahq+ci;")i EmNW`0}d\K?QD-ki'e1ACa%i^\|.I$a-4>b(L ** The Adult Core Set includes the NCQA version of the measure, whichis adapted from the CMS measure (NQF #1879). In light of these points, a blueprint is proposed for using domain-specific outcome measures in stroke recovery trials. The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. This section includes the measure type (inpatient vs outpatient), the number of measures in the set, which certification the measure set is a part of, a list of the measures in the set and the associated algorithm. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter/month for the sub-population cannot sample that sub-population. Patient education should include information about the event (e.g., cause, treatment, and risk factors), the role of various medications or strategies, as well as desirable lifestyle modifications to reduce risk or improve outcomes. <> Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. Set the Initial Patient Population Reject Case Flag to equal Yes. Studies at this time suggest that antithrombotic therapy should be administered within 2 days of symptom onset in acute ischemic stroke patients to reduce stroke mortality and morbidity. stroke patients receiving IV t-PA at your hospital who are treated within 45 minutes after triage (ED arrival). Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size is less than the minimum required quarterly sample size, so 100% of the subpopulation or all 37 cases are sampled. <>>> The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. Measure Set Stroke Measure ID # STR-1 Measure Name Prehospital Screening for Suspected Stroke Patients The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. promotion of measurement that is evidence-based and generates valuable information for quality improvement, reduction in the variability in measure selection, and. 671 0 obj <>/Filter/FlateDecode/ID[<8968A4F338E55446928FCF4A155C4BC8>]/Index[646 45]/Info 645 0 R/Length 114/Prev 86415/Root 647 0 R/Size 691/Type/XRef/W[1 2 1]>>stream Of FSRMC patients treated with tPA, a clot-dissolver, or who underwent a procedure to retrieve a blood clot, 2.4% experienced complications, compared to the national average complication rate of 6.8%. The following are Stroke chart abstracted measures used by The Joint Commission. Here is a diagram that outlines the submission differences. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. If the Principal Diagnosis code falls on Table 8.1 it will be placed in the Ischemic Stroke, or sub-pop 1 and if it has a Principal Diagnosis code that falls on Table 8.2, then it will be placed in the Hemorrhagic Stroke or sub-pop-2. 690 0 obj <>stream Using the monthly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 11 cases are sampled. Additionally, the Collaborative developed a framework of aims and principles that informed the selection of core measure sets. <> Saturday: 9 a.m. - 5 p.m. CT All rights reserved. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. CPT only copyright 2019 American Medical Association. Core Rulebook (disambiguation) This is a disambiguation page; that is, one that points to other pages that might otherwise have the same name.Pathfinder 2E.Expand your capabilities by selecting general feats that improve your statistics or give you. The Differences Between The 5 Major Stroke Measure Sets, Thrombolytic Therapy: Inpatient Admission, Antithrombotic Therapy By End of Hospital Day 2, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible, Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO, National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients), Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship), CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only, CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade), 1. STK-OP-1a Overall Rate (Not Reported2. STK-5 Antithrombotic Therapy By End of Hospital Day Two8. The Perfect Care Report identifies patients that received perfect care. In the specifications manual, Version 2021B, it is in Section 7: Joint Commission National Quality Measures Data Processing, Joint Commission Stroke Measures table: https://manual.jointcommission.org/releases/TJC2021B/TransmissionChapterTJC.html. STK-OP-1g Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**8. Part 2: A review of the different stroke certifications. Stroke Core Measure - About Us - Mayo Clinic , . CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy, 4. 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Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs, Measures for Acute Stroke Ready Center Certification, Measures for Primary Stroke Center Certification, Measures for Thrombectomy Capable Stroke Center Certification, Measures for Comprehensive Stroke Center Certification, eSTK-2 Discharged on Antithrombotic Therapy, eSTK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter, eSTK-5 Antithrombotic Therapy by End of Hospital Day Two, ASR-IP-1 Thrombolytic Therapy: Inpatient Admission, ASR-IP-2 Antithrombotic Therapy By End of Hospital Day 2, ASR-IP-3 Discharged on Antithrombotic Therapy, ASR-OP-1 Thrombolytic Therapy: Drip and Ship, CSTK-01 National Institutes of Health Stroke Scale (NIHSS) Score Performed for Ischemic Stroke Patients, CSTK-02 Modified Rankin Score (mRS) at 90 Days, CSTK-03 Severity Measurement Performed for SAH and ICH Patients, CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH), CSTK-06 Nimodipine Treatment Administered, CSTK-08 Thrombolysis in Cerebral Infarction (TICI) Post-Treatment Reperfusion Grade, CSTK-10 Modified Rankin Score (mRS) at 90 Days: Favorable Outcome, CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival, CSTK-12 Rate of Rapid Effective Reperfusion From Skin Puncture, STK-1 Venous Thromboembolism (VTE) Prophylaxis, STK-2 Discharged on Antithrombotic Therapy, STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter, STK-5 Antithrombotic Therapy By End of Hospital Day Two, STK-OP-1 Door to Transfer to Another Hospital, STK-VOL-1 Eligible Ischemic Stroke Patients Who Receive Mechanical Endovascular Reperfusion Therapy. See how our expertise and rigorous standards can help organizations like yours. This item requires a Core Return or Core Charge. CSTK-09a Time (in minutes) from hospital arrival to skin puncture in patients with acute ischemic stroke who are transferred from another hospital and undergo endovascular treatment, CSTK-09b Time (in minutes) from hospital arrival to skin puncture in patients with acute ischemic stroke who present directly to your hospital and undergo endovascular treatment, Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH ), 2. Mayo Clinic does not endorse any of the third party products and services advertised. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. They also could require other measures. CSTK-03 Severity Measurement Performed for SAH and ICH Patients (Overall Rate)3. STK-6 Discharged on Statin Medication17. Core Measures are evidence-based standards of care established by The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). This is a big year for Quality. 4= highly recommended; the outcome measure has excellent psychometric properties and clinical utility. One-hundred and twenty-three (123) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. stream STK-8 Stroke Education13. Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). endobj Using the monthly sampling table for the Hemorrhagic sub-population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. The next measure set we review is abbreviated ASR-IP/OP. ruTv?U J4lUBex(a8{g$CHj ~>-z I&8:+hlvM(XdvY;D|BOl,Yu'D> YR9Gbl6GrJ8'},^V)\i/0 Gg:} >!81I88{'swe )I6v#{$&YymLyn\tl S3r6.o?x@q$_1A=U$H3%QUx . These measures include aggressive use of medications, such as antithrombotics, anticoagulation therapy, deep vein thrombosis prophylaxis, cholesterol-reducing drugs and smoking cessation, all aimed at reducing death and disability and improving the lives of stroke patients. Use the month and day portion of admission date and birthdate to yield the most accurate age. CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. Each certification may require your hospital to submit one or more of the five measure sets we reviewed above. Quarterly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 392 during the first quarter. These measures include intravenous thrombolysis, deep vein thrombosis prophylaxis, dysphagia screening, stroke education, and discharge-related medications and assessments. hbbd``b` SY ~H0[@D1HI-Hp @o$xA }:.PHplp%H^'n&F&QT'340 Ji STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter6. 2018 - 2021. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Request Appointment Quality and Mayo Clinic Arizona Florida Minnesota Event reporting Quality measures Quality rankings Stroke Core Measure Loading chart. TARGET: STROKE MEASURE Door to IV rt-PA in 60 minutes (Historic-Quality): Percent of ischemic stroke patients receiving IV t-PA at your hospital who are treated within 60 minutes after triage (ED arrival). The Core Quality Measures Project currently includes 6 of 11 National EMS Quality Measures. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. CMS will go through a public notice and comment rule-making for implementation of these core sets and looks forward to public input on the measures included in these core measure sets. The change in the performance measure requirements for Acute Stroke Ready Hospitals, (i.e., STK-OP-1 replacing ASR-OP-2 effective with discharges on and after July 1, 2021) can be found in several places. CSTK-09 Arrival Time to Skin Puncture, 1. Calculate the Length of Stay. >0SPJ*@6W/rq+ERY_X&14>k( Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. Sign up to get the latest information about your choice of CMS topics. Secure .gov websites use HTTPSA To submit a research proposal for the Get With The Guidelines- Stroke program, email a completed Get With The Guidelines Data Request Form (download) to [emailprotected]. STK-OP-1h Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible**ADDED as of 7/1/2021**9. The two sub-populations must be sampled independently from each other. Specifications Manual for Joint Commission National Quality Measures (v2021A1), Comprehensive Stroke (CSTK) Initial Patient Population, First Pass of a Mechanical Reperfusion Device, Highest NIHSS Score Documented Within 36 Hours Following IA Alteplase or MER Initiation, Highest NIHSS Score Documented Within 36 Hours Following IV Alteplase Initiation, IV Alteplase Prior to IA or Mechanical Reperfusion Therapy, Initial Blood Glucose Value at Hospital Arrival, Initial Blood Pressure at Hospital Arrival, Initial Platelet Count at Hospital Arrival, NIHSS Score Documented Closest to IA Alteplase or MER Initiation, NIHSS Score Documented Closest to IV Alteplase Initiation, Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade, Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Date, Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time, Reason for Not Administering Nimodipine Treatment, Reason for Not Administering a Procoagulant Reversal Agent, Appendix E - Overview of Measure Information Form and Flowchart Formats, Cover Page for the Joint Commission Manual, Joint Commission Clinical Data Processing Flow, Joint Commission National Quality Measures Data Processing, Using the The Joint Commission's National Measure Specifications Manual, National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients), Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH ), Hemorrhagic Transformation (Overall Rate), Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade), Modified Rankin Score (mRS at 90 Days: Favorable Outcome), Rate of Rapid Effective Reperfusion From Hospital Arrival, Rate of Rapid Effective Reperfusion From Skin Puncture, All Records, Not collected for HBIPS-2 and HBIPS-3, All Records, Optional for HBIPS-2, HBIPS-3, All Records, Optional for All HBIPS Records. This Agreement will terminate upon notice if you violate its terms. Family/caregivers will also need guidance in planning effective and realistic care strategies appropriate to the patient's prognosis and potential for rehabilitation. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 84 cases for the quarter. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size is less than the minimum required quarterly sample size, so 100% of the subpopulation or all 67 cases are sampled. Forty states reported at least half (16) of the Adult Core Set measures for FFY 2019. A hospital may choose to use a larger sample size than is required. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. MjMO2n7( LBm6N.Hl#|oKP?lEF@L9ew,w\XpP{]8vxmtV}Or,kU{ `B7{"'Tf(DL[}ZEY 7'XoFo(|{%Jlv,_v}%DPnpoAucQGPy'YVJGXv:E j5(kts,?BcBKd?R . This is increasingly important as the health care system moves towards value-based reimbursement models. Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. Using the quarterly sampling table for the Ischemic sub-population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. This section reviews The Joint Commission certifications and clarifies the CMS accreditation requirement.

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