stroke core measures 2021 stroke core measures 2021

Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the month. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)5. Stroke Performance Measure 1: VTE Prophylaxis (ischemic and hemorrhagic stroke patients who received STK-8 Stroke Education10. Repeat steps 8 and 9 until your team is happy with your treatment rates and your hospital is eligible for. 1-800-242-8721 To address this problem, the Centers for Medicare & Medicaid Services (CMS), commercial plans, Medicare and Medicaid managed care plans, purchasers, physician and other care provider organizations, and consumers worked together through the Core Quality Measures Collaborative to identify core sets of quality measures that payers have committed to using for reporting as soon as feasible. The administration of anticoagulation therapy is an effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients. It is difficult to have actionable and useful information because physicians and other clinicians must currently report multiple quality measures to different entities. CSTK-03 Severity Measurement Performed for SAH and ICH Patients (Overall Rate)3. Measure Type: OutpatientNumber of Measures Included: There are five process measures (youll see one additional measure listed below that is not reported and one additional measure that is retired starting with July 1, 2021 discharges). For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form (PDF). Core Measures are evidence-based standards of care established by The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). Find the exact resources you need to succeed in your accreditation journey. Set the Initial Patient Population Reject Case Flag to equal Yes. This is a big year for Quality. A hospitals Ischemic sub-population is 316 during January. CMIT searches all fields in the inventory and is not case-sensitive. In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. hbspt.cta._relativeUrls=true;hbspt.cta.load(491484, '41fd9d46-8610-4a5f-a135-c143fe55a31f', {"useNewLoader":"true","region":"na1"}); By JoAnne Marino April 30, 2021 Regulatory Updates: Hospital. 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. Regulatory/AccreditationExamples would include the Center for Medicare & Medicaid Services (CMS) required core measures (e.g., fibrinolytic therapy received within 30 minutes of emergency department (ED) arrival, aspirin at arrival) and documentation of Joint Commission standard achievement. Length of Stay, in days, is equal to the Discharge Date minus the Admission Date. A single copy of these materials may be reprinted for noncommercial personal use only. Studies suggest that antithrombotic therapy should be prescribed at hospital discharge following an ischemic stroke to reduce stroke mortality and morbidity. The following links provide you with information available on past, present and future versions of the specification manuals, including release notes, measure information forms, data dictionaries, missing and invalid data, population and sampling, data transmission, tools and resources, and appendices. 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. So, Ive attempted to structure it in a way that will be a reference for you. 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%. Saturday: 9 a.m. - 5 p.m. CT sI Measure Information 2021 Reporting Period; CMS eCQM ID: CMS71v10 Short Name: STK-3 NQF Number: Not Applicable Description: Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy at hospital discharge. The Duke Health system tracks and measures the care we provide to our patients based on these quality measures. LqV)%0w#lP.s9XsG58gX'5L S AP*=;%)e0J9_T-NXC4*~bTdsSFnde#;nOOyOqsi]qQV/Fb3KtK. It is important to always refer to the latest edition. Approximately 2-4% of patients with stroke have their event while hospitalized for another condition, with almost one half resulting from a vascular procedure. If the Patient Age is greater than or equal to 18 years, continue processing and proceed to Length of Stay Calculation. CSTK-06 Nimodipine Treatment Administered6. Family/caregivers will also need guidance in planning effective and realistic care strategies appropriate to the patient's prognosis and potential for rehabilitation. Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . February 2021 intimacy and sex after stroke February 2021 Post-stroke outcome, falls and fatigue February 2021 improving stroke care. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter6. Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. Measure Type: InpatientNumber of Measures Included: 8Certification Requirement: The Joint Commissions Primary Stroke Certification, Anticoagulation Therapy for Atrial Fibrillation/Flutter, Antithrombotic Therapy By End of Hospital Day Two. Time from symptom onset to stroke alert is delayed in in-hospital stroke. A hospitals hemorrhagic stroke patient population size is 392 cases during the second quarter. A hospitals ischemic stroke patient population size is 37 cases during the second quarter. 2018 - 2021. A hospitals Hemorrhagic sub-population is 316 during February. All rights reserved. 1 0 obj CSTK-12 Rate of Rapid Effective Reperfusion From Skin Puncture11. The Measure Steward refers to the organization that is responsible for providing the required measure information for the measure maintenance process that occurs approximately every three years. Disclaimer of Warranties and Liabilities. 2 0 obj Monthly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 228 during March. Especially if you use an EHR vendor right now, youll notice a huge difference. STK-OP-1a Overall Rate (Not Reported2. CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. 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 AMA does not directly or indirectly practice medicine or dispense medical services. %PDF-1.4 % Refine processes and protocols to ensure they are in line with the guidelines. Based on this review and discussion the workgroups identified a consensus core set for the selected clinical areas. 1 0 obj Forty states reported at least half (16) of the Adult Core Set measures for FFY 2019. A hospitals hemorrhagic stroke patient population size is 200 cases during the second quarter. There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only2. The AMA does not directly or indirectly practice medicine or dispense medical services. CPT is a registered trademark of the American Medical Association. Statin drugs are medications used to reduce serum level of lipids such as cholesterol. TJC is adding three additional measures beginning with July 1, 2021 discharges.Certification Requirement: The Joint Commissions Primary Stroke Certification, Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) **RETIRED 7/1/2021**, Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible, Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible, Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible **ADDED as of 7/1/2021**, Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, Measure Type: OutpatientNumber of Measures Included: 1 process measureAccreditation Requirement: CMS Outpatient Quality Reporting program. Unauthorized use prohibited. 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. A modified sampling procedure is required for hospitals performing quarterly sampling for STK. 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. endobj U.S. Government Rights The following are Stroke chart abstracted measures used by The Joint Commission. But hospitals see benefits as well. 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. CPT only copyright 2019 American Medical Association. with acute ischemic stroke in the hospital setting will submit this measure. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. The goal is to quickly get rid of any blood clot(s) to restore function to the area that is impacted by a stroke, such as the brain. Stroke Core Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 . 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. lock STK-1 Venous Thromboembolism (VTE Prophylaxis)7. Percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. A hospitals hemorrhagic stroke patient population size is 129 cases during March. Patients admitted to the hospital for inpatient acute care are included in the CSTK 3-Hemorrhagic Stroke subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 8.2, a Patient Age (Admission Date Birthdate) 18 years and a Length of Stay (Discharge Date - Admission Date) 120 days. hWn8,CIDE ;its8MZAt,9!%_e'Kaxs8>f9! CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only3. The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival10. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, 9. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 14 cases for the month. If you search for multiple terms, CMIT will return all deliverables containing at least one of the terms. U.S. Government Rights Process all cases that have successfully reached the point in the Clinical Data Processing Flow which calls this Initial Patient Population Algorithm. CPT is provided as is without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. STK-OP-1g Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**8. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, Rate of Rapid Effective Reperfusion From Hospital Arrival. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. endstream endobj 647 0 obj <>/Metadata 18 0 R/Pages 644 0 R/StructTreeRoot 24 0 R/Type/Catalog/ViewerPreferences<>>> endobj 648 0 obj <>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/StructParents 1/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 649 0 obj <>stream 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. Additionally, the Collaborative developed a framework of aims and principles that informed the selection of core measure sets. 4 0 obj % 3 0 obj . Source: Medisolv Perfect Care Report (eff. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 20% of this subpopulation or 78 cases for the quarter (20% of 392 equals 78.4 rounded to the next highest whole number equals 78). STK-2 Discharged on Antithrombotic Therapy5. Data Source: American Heart Association Get With The Guidelines stroke database. Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Rate of Rapid Effective Reperfusion From Skin Puncture. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 20% of this subpopulation or 45 cases for the quarter (20% of 223 equals 44.6 rounded to the next highest whole number equals 45). The American Medical Association does not agree to license CPT to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. Submission of aggregate data is still required. This product includes CPT which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. Measure 6a is new and is being pilot tested in 2009. 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. %%EOF STK-1 Venous Thromboembolism (VTE Prophylaxis)12. Patients admitted to the hospital for inpatient acute care are included in the CSTK 1-Ischemic Stroke Without Procedure subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 8.1, a Patient Age (Admission Date Birthdate) 18 years and a Length of Stay (Discharge Date - Admission Date) 120 days. Start STK Initial Patient Population logic sub-routine. Using the monthly sampling table for the Hemorrhagic sub-population, the sample size required is 20% of this sub-population, or 46 cases for the quarter (twenty percent of 228 equals 45.6 rounded up to the next whole number equals 46). These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. %PDF-1.5 lock STK-1 Venous Thromboembolism (VTE Prophylaxis)4. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 50 cases for the month. }J promotion of measurement that is evidence-based and generates valuable information for quality improvement, reduction in the variability in measure selection, and. Quarterly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 392 during the first quarter. A hospitals hemorrhagic stroke patient population size is 295 cases during March. Closed on Sundays. Drive performance improvement using our new business intelligence tools. The guiding principles used by the Collaborative in developing the core measure sets are that they be meaningful to patients, consumers, and physicians, while reducing variability in measure selection, collection burden, and cost. The six measures are: . % Joint Commission Clinical Measures. CSTK-05 Hemorrhagic Transformation, 1. CQMC will release four additional updated core measure sets and two new core measure sets over the coming months. 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 Researchers also have the opportunity to conduct investigator-led research projects using data from the Get With The Guidelines- Stroke program. endobj Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 75 cases for the quarter. Mayo Clinic does not endorse any of the third party products and services advertised. 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. STK-2 Discharged on Antithrombotic Therapy8. <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> 3= recommended; the outcome measure has good psychometric . <> In light of these points, a blueprint is proposed for using domain-specific outcome measures in stroke recovery trials. Heres a link to TJCs full program comparison sheet with guidelines of certification requirements. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. A hospital may choose to use a larger sample size than is required. The coalition was convened in 2015 by Americas Health Insurance Providers (AHIP) and the Centers for Medicare & Medicaid Services (CMS) and is housed at the National Quality Forum (NQF). The AMA is a third party beneficiary to this Agreement. The required quarterly sample sizes for each sub-population would be 79 and 5. A hospitals Ischemic sub-population is 5 patients during the first quarter. Written by American Heart Association editorial staff and reviewed by science and medicine advisers. An IV injection of recombinant tissue plasminogen activator (TPA) also called alteplase (Activase) or tenecteplase (TNKase) is the gold standard treatment for ischemic stroke. 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. 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, 6. Suspected stroke symptoms can be confounded by medications, metabolic encephalopathy, and comorbid conditions. An antithrombotic agent is a drug that reduces the formation of blood clots. STK-5 Antithrombotic Therapy By End of Hospital Day Two16. Hospitals now have one place to submit both chart-abstracted and eCQM data. A hospitals ischemic stroke patient population size is 200 patients during the second quarter. CSM special February 2021 Motor planning after stroke CSM special January 2021 January 2021 Stroke SIG and CSM 2 January 2021 Stroke SIG and CSM January 2021, Locomotor Podcast - Intensity and stepping.