Managing the Measures: A Serious Look at Key Abstraction Concepts for the Comprehensive Stroke (CSTK) Measure Set Session 2

Transcription

1 Managing the Measures: A Serious Look at Key Abstraction Concepts for the Comprehensive Stroke (CSTK) Measure Set Session 2 January 28, to 3 PM Central Time

2 Continuing Education Credit This course is approved for 2.0 hours CE credit by the Accreditation Council for Continuing Medical Education (ACCME), the American Nurses Credentialing Center s Commission on Accreditation (ANCC), the American College of Healthcare Executives (ACHE), and.20 CEU by the International Association for Continuing Education and Training (IACET). To receive credit, participants must attest that they have listened to the program in its entirety, and submit a completed online evaluation after the program. 4

3 Continuing Education Credit Because The Joint Commission is an accredited provider of continuing education, participants attending this event will receive continuing education certificates of completion after submitting a completed post-evaluation. A link to the post-evaluation will be sent via to all registered participants after the close of this program. The link to the post-evaluation will remain open until February 6, Please complete and return your evaluation prior to this date to receive credit. 5

4 Disclosure The speaker has disclosed that she does not have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity. 6

5 Karen Kolbusz, RN, BSN, MBA Associate Project Director Division of Healthcare Quality Evaluation The Joint Commission

6 Session 2 Review the new comprehensive stroke (CSTK) measures CSTK-05 CSTK-08 CSTK-07 CSTK-02 Provide opportunity for questions 8

7 The Final CSTK Measure Set 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 Subarachnoid Hemorrhage (SAH) and Intracerebral Hemorrhage (ICH) Patients (Overall Rate) CSTK-04: Procoagulant Reversal Agent Initiation CSTK-05: Hemorrhagic Transformation (Overall Rate) CSTK-06: Nimodipine Treatment Administered CSTK-07: Median Time to Revascularization CSTK-08: Thrombolysis in Cerebral Infarction (TICI) Post-Treatment Reperfusion Grade 9

8 Disease-Specific Care CERTIFICATION PROGRAM Comprehensive Stroke PERFORMANCE MEASUREMENT IMPLEMENTATION GUIDE January 2015

9 Three Sub-populations Ischemic stroke patients without intervention (1) Ischemic stroke patients with IV t-pa, IA t-pa, or mechanical reperfusion (MER) therapy (2) Hemorrhagic Stroke Patients (3) Subarachnoid hemorrhage Intracerebral hemorrhage 11

10 CSTK Initial Patient Population ICD-9-CM Principal Diagnosis Code for ischemic or hemorrhagic stroke Patient Age (Admission Date minus Birthdate) > 18 years Length of Stay (Discharge Date minus Admission Date) < 120 days

11 Initial Patient Population con t 3 ICD-9-CM Principal Diagnosis Code for ischemic or hemorrhagic stroke 1 2 ICD-9-CM Principal or Other Procedure Code for thrombolytic therapy or mechanical endovascular reperfusion therapy

12 Data Elements Admission Date Birthdate Discharge Date ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Codes Note: The initial patient population is the foundation for each individual measure denominator population. 14

13 Excluded Populations Patients less than 18 years of age Patients who have a Length of Stay greater than 120 days Initial patient population algorithm Note: Excluded from each individual measure denominator population. 15

14 CSTK-05 Hemorrhagic Transformation Rationale: Intravenous (IV) thrombolytic (t-pa) therapy for acute ischemic stroke was approved by the US Food and Drug Administration in 1996, following findings from the National Institute of Neurological Disorders and Stroke (NINDS) trial which demonstrated favorable outcomes in 31% to 50% of patients treated with recombinant tissue plasminogen activator (r-tpa), as compared to 20% to 38% of patients treated with placebo. Intra-arterial (IA) thrombolytic therapy (t-pa) has since been used to improve recanalization and clinical outcomes for select patients nonresponsive to IV therapy Mechanical endovascular thrombectomy is a treatment option for patients with large vessel occlusions in whom pharmacological thrombolysis is contraindicated or might be ineffective Type of Measure: Outcome 16

15 CSTK-05 Hemorrhagic Transformation Denominator: Ischemic stroke patients treated with IV t-pa only (IVO), IA t-pa, or mechanical endovascular reperfusion (MER) therapy Numerator: Ischemic stroke patients who develop a symptomatic intracranial hemorrhage < 36 hours after the onset of treatment with IV t-pa, IA t-pa, or MER therapy 17

16 Stratified by Procedure Code and Route of t-pa Administration CSTK-05a Intravenous (IV) thrombolytic (t-pa) therapy only CSTK-05b Intra-arterial (IA) thrombolytic (t-pa) therapy, or Mechanical endovascular reperfusion (MER) therapy

17 CSTK-05 Hemorrhagic Transformation Denominator: Ischemic stroke patients treated with IV t-pa only (IVO), IA t-pa, or mechanical endovascular reperfusion (MER) therapy Sub-Population: CSTK 2 Ischemic Stroke With IV t-pa, IA t-pa, or MER 19

18 CSTK-05 Included Populations Denominator: Discharges with an ICD-9-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A, Table 8.1, AND 20

19 CSTK-05 Included Populations Denominator: Patients with documented thrombolytic (IV or IA t-pa) therapy (ICD-9-CM Principal or Other Procedure Codes as defined in Appendix A, Table 8.1a), OR Table 8.1a Thrombolytic Agent Procedures Code Shortened Description INJECTION OR INFUSION OF THROMBOLYTIC AGENT 21

20 CSTK-05 Included Populations Denominator: Patients with documented Mechanical Endovascular Reperfusion Therapy (ICD-9-CM Principal or Other Procedure Codes as defined in Appendix A, Table 8.1b) Table 8.1b Code Mechanical Endovascular Reperfusion Procedures Shortened Description ENDOVASC EMBOL HD/NK VES ENDO REM OBS HD/NECK VES ENDO EMB HD/NK BARE COIL ENDO EM HD/NK, BIOAC COIL 22

21 CSTK-05 Excluded Populations Denominator: Patients admitted for Elective Carotid Intervention Patients transferred to this hospital following treatment with IV or IA thrombolytic (t-pa) therapy or mechanical endovascular reperfusion therapy initiated prior to arrival at this hospital 23

22 CSTK-05 Excluded Populations Denominator: Patients who hemorrhage prior to the onset of treatment with IV or IA thrombolytic (t-pa) therapy or mechanical endovascular reperfusion therapy 24

23 CSTK-05 Data Elements Denominator: Elective Carotid Intervention ICD-9-CM Other Diagnosis Codes ICD-9-CM Other Procedure Dates ICD-9-CM Principal Procedure Date Measure specific data elements 25

24 CSTK-05 Algorithm Highlights Measure Category X = Missing/Invalid Data Measure Category B = Exclusion

25 CSTK-05 Hemorrhagic Transformation Numerator: Ischemic stroke patients who develop a symptomatic intracranial hemorrhage < 36 hours after the onset of treatment with IV t-pa, IA t-pa, or MER therapy 27

26 CSTK-05 Data Elements Numerator: Arrival Date Arrival Time Highest NIHSS Score Documented Within 36 Hours Following IA t-pa or MER Initiation Highest NIHSS Score Documented Within 36 Hours Following IV Thrombolytic Initiation 28

27 CSTK-05 Data Elements Numerator: IA Route of t-pa Administration IA t-pa or MER Initiation Date IA t-pa or MER Initiation Time IV Thrombolytic Initiation Date IV Thrombolytic Initiation Time 29

28 CSTK-05 Algorithm Highlights Subpopulation CSTK 2 IV t-pa only patients IA t-pa or MER patients

29 CSTK-05 Algorithm Highlights IA t-pa or MER path IA t-pa or MER procedure done at your hospital

30 CSTK-05 Data Elements Numerator: NIHSS Score Documented Closest to IA t-pa or MER Initiation NIHSS Score Documented Closest to IV Thrombolytic Initiation Positive Brain Image Positive Brain Image Date Positive Brain Image Time 32

31 CSTK-05 Algorithm Highlights Within 36 hours

32 CSTK-05 Algorithm Highlights Sequence repeated for IVO path (Timing II, Timing IV, Deterioration 2 Measure Category E = Numerator

33 CSTK-05 DE Definition Example: 35

34 IA Route of t-pa Administration Notes for Abstraction: If both IV and IA thrombolysis are given either in different procedures or the same procedure, select Yes If the only route of thrombolytic administration was intra-venous (IV) at this hospital or a transferring hospital, select No If IA t-pa given at a transferring hospital and NOT your hospital, select NO 36

35 IA Thrombolytic Initiation Date / IA Thrombolytic Initiation Time Notes for Abstraction: If date / time is unable to be determined, select UTD Look for a documented infusion time or start time of the IA thrombolytic bolus or infusion in the medical record Use the time IA thrombolytic was first documented. Multiple times or a discrepancy, choose the earliest time 37

36 NIHSS Score Documented Closest to IA t-pa or MER Initiation Definition: The NIHSS score documented closest to IA thrombolytic (t-pa) therapy or mechanical endovascular reperfusion (MER) therapy initiation is the last NIHSS score documented prior to IA t-pa or MER initiation (i.e., the initiation time of the intervention performed first) at this hospital 38

37 NIHSS Score Documented Closest to IA t-pa or MER Initiation Data Collection Question: What is the last NIHSS score documented prior to initiation of IA t-pa or MER at this hospital? Allowable Values: Score = 0-42 UTD = Unable to Determine 39

38 NIHSS Score Documented Closest to IA t-pa or MER Initiation Notes for Abstraction: Documented by the physician/apn/pa or nurse (RN) Select the last NIHSS score documented prior to the start time of IA t-pa OR first pass of a mechanical reperfusion device whichever intervention is performed first, (i.e. IA t-pa first then MER or MER first then IA t-pa ), at this hospital 40

39 NIHSS Score Documented Closest to IA t-pa or MER Initiation Notes for Abstraction: If only one NIHSS score is documented prior to IA t-pa or MER initiation, enter the value for that score If no NIHSS score is documented prior to IA t-pa or MER initiation, select UTD. If unable to determine the last NIHSS score documented prior to IA t-pa or MER initiation, select UTD 41

40 NIHSS Score Documented Closest to IA t-pa or MER Initiation Exclusion Guidelines for Abstraction: Modified NIHSS scores Estimated NIHSS scores Scoring methodologies other than NIHSS Note: Exclusion Guidelines for Abstraction listed in a data element means that these items do NOT count select NO 42

41 Highest NIHSS Score Documented Within 36 Hours Following IA t-pa or MER Initiation Notes for Abstraction: Look for the highest NIHSS score documented in less than or equal to 36 hours following initiation of IA t-pa or MER therapy If multiple scores are documented within the first 36 hours following initiation of IA t-pa or MER therapy, select the highest 43

42 Positive Brain Image Notes for Abstraction: Documentation of a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage following IV or IA t-pa, OR MER therapy initiation The major risk of reperfusion therapy is hemorrhage 44

43 Positive Brain Image Notes for Abstraction: For purposes of this data element, do not use brain imaging reports for CT/MRI performed prior to IV or IA thombolytic (t-pa) initiation, or mechanical endovascular reperfusion (MER) therapy Abstract only brain imaging reports for tests done after these interventions to select YES 45

44 Positive Brain Image Notes for Abstraction: For patients with a positive finding of hemorrhage on brain imaging following IV or IA t-pa or MER initiation, select YES A confirmed report is not necessary. Reports of preliminary findings within this timeframe may be used in abstraction Findings suggestive of hemorrhage or conflicting documentation, select YES 46

45 Positive Brain Image ONLY acceptable data sources: Brain imaging reports Diagnostic test reports Radiology reports 47

46 Positive Brain Image Inclusion Terms Bleed Brain hemorrhage Cerebral hemorrhage ECASS criteria PH1 or PH2 Hemorrhage Hemorrhagic conversion Hemorrhagic expansion Hemorrhagic transformation Intracerebral hemorrhage (ICH) Intraventricular hemorrhage Parenchymal hematoma Parenchymal hemorrhage Parenchymal intracerebral hemorrhage Petechial hemorrhage Subarachnoid hemorrhage (SAH)

47 Positive Brain Image Date / Time Notes for Abstraction: Use the first documented date/time of positive brain image finding following IV or IA t-pa, or MER therapy If a discrepancy exists in date/time documentation from different sources, choose the earliest date Two or more different positive brain image dates, enter the earliest date Unable to be determine, select UTD 49

48 CSTK-05 Algorithm Highlights CSTK-05 Overall Rate Measure Category Assignments IV t-pa only patients IA t-pa or MER patients

49

50 CSTK-08 TICI Post-Treatment Reperfusion Grade Rationale: The Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade is used to measure cerebral reperfusion. Four results are possible with this scoring system: 0 (no perfusion); 1 (perfusion past the initial occlusion, but no distal branch filling); 2 (perfusion with incomplete or slow distal branch filling); and 3 (full perfusion with filling of all distal branches)... The Interventional Management of Stroke (IMS) I trial suggested that the combined use of reduced-dose intravenous (IV) thrombolytic (t-pa) therapy, followed by microcatheter delivered intra-arterial (IA) thrombolytic (t-pa) therapy, was safe and effective in selected ischemic stroke patients, as compared to patients treated with full dose IV t-pa in the National Institute of Neurologic disease and Stroke (NINDS) rt-pa trial. In IMS I, a final TICI 2/3 reperfusion was achieved in 62% of ischemic stroke patients treated. Type of Measure: Outcome 52

51 CSTK-08 TICI Post-Treatment Reperfusion Grade Denominator: Ischemic stroke patients treated with IA t-pa and or MER therapy Numerator: Ischemic stroke patients with a post-treatment reperfusion grade of TICI 2B or higher 53

52 CSTK-08 TICI Post-Treatment Reperfusion Grade Denominator: Ischemic stroke patients treated with IA t-pa and or MER therapy Sub-Population: CSTK 2 Ischemic Stroke With IV t-pa, IA t-pa, or MER 54

53 CSTK-08 Included Populations Denominator: Discharges with an ICD-9-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A, Table 8.1, AND 55

54 CSTK-08 Included Populations Denominator: Patients with documented thrombolytic (IV or IA t-pa) therapy (ICD-9-CM Principal or Other Procedure Codes as defined in Appendix A, Table 8.1a), OR Table 8.1a Thrombolytic Agent Procedures Code Shortened Description INJECTION OR INFUSION OF THROMBOLYTIC AGENT 56

55 CSTK-08 Included Populations Denominator: Patients with documented Mechanical Endovascular Reperfusion Therapy (ICD-9-CM Principal or Other Procedure Codes as defined in Appendix A, Table 8.1b) Table 8.1b Code Mechanical Endovascular Reperfusion Procedures Shortened Description ENDOVASC EMBOL HD/NK VES ENDO REM OBS HD/NECK VES ENDO EMB HD/NK BARE COIL ENDO EM HD/NK, BIOAC COIL 57

56 CSTK-08 Excluded Populations Denominator: Patients admitted for Elective Carotid Intervention 58

57 CSTK-08 Data Elements Denominator: Elective Carotid Intervention IA Route of t-pa Administration Measure specific data elements 59

58 CSTK-08 Algorithm Highlights No IA = IV t-pa, Case excluded; Yes IA, case included

59 CSTK-08 TICI Post-Treatment Reperfusion Grade Numerator: Ischemic stroke patients with a post-treatment reperfusion grade of TICI 2B or higher 61

60 CSTK-08 Data Elements Numerator: Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade 62

61 Post-Treatment TICI Definition: Documentation that the Thrombolysis in Cerebral Infarction (TICI) reperfusion grade was 2B (i.e., partial perfusion greater than or equal to 50% of vascular distribution of occluded artery) or higher post-treatment. 63

62 Post-Treatment TICI Allowable Values: 1 A TICI reperfusion grade greater than or equal to ( ) 2B was documented posttreatment 2 A TICI reperfusion grade less than (<) 2B was documented post-treatment 3 A TICI reperfusion grade was not done post-treatment, OR Unable to determine (UTD) from the medical record documentation 64

63 Post-Treatment TICI Notes for Abstraction: Physician/APN/PA documentation of the TICI grade only Exclusion Guidelines for Abstraction: TIBI TIMI Scoring methodologies other than TICI 65

64 CSTK-08 Algorithm Highlights 2 = < TICI 2B 3 = UTD Measure Category E = Numerator 1 = > TICI 2B

65 Risk Adjustment Data Elements Outcome measures need to be adjusted for risk Risk Adjustment data elements are collected of CSTK-05 and CSTK-08 Risk adjustment data elements are NOT used in the algorithms to calculate the measure rate Risk adjustment data elements are patientlevel data collected to develop the risk adjustment model for these measures 67

66 Risk Adjustment Data Elements Admission Date Birthdate Hispanic Ethnicity ICD-9-CM Other Diagnosis Codes IV Thrombolytic Therapy Prior to IA or Mechanical Reperfusion Therapy Initial Blood Glucose Value at Hospital Arrival Initial Blood Pressure at Hospital Arrival Initial NIHSS Score at Hospital Arrival Initial Platelet Count at Hospital Arrival Proximal or Distal Occlusion Race Sex Site of Primary Vessel Occlusion

67 Abstraction Tips Note the Format for data entry detailed in the data element definition Initial Platelet Count at Hospital Arrival requires a 6 character value, no comma, no decimal (e.g., ) Use abstraction guidelines to help identify acceptable values, e.g., location of testing, testing methods such as Point of Care (POC) Review values obtained prior to and after hospital arrival to select the earliest value 69

68 Abstraction Tips Initial NIHSS Score at Hospital Arrival is the earliest documented NIHSS score and may have been done by EMS, teleneurology or a transferring hospital. The data element definition is NOT the same as the definition for Initial NIHSS Score Performed (CSTK-01) Initial NIHSS Score Performed asks for scores done at your hospital, allowable values Yes / No 70

69

70 CSTK-07 Median Time to Revascularization Rationale: Timely recanalization of an occluded intracerebral artery is a strong predictor of improved functional outcome and reduced mortality in patients with an acute ischemic stroke. At this time, administration of intra-venous (IV) tissue plasminogen activator (t-pa) within three hours of time last known well remains the recommended first-line approach. However, the short therapeutic window and low rates of recanalization with IV thrombolytic (t- PA) therapy has prompted the investigation of alternative approaches via intra-arterial infusion of a thrombolytic drug or mechanical recanalization with a clot retrieval device. Since time is brain, the overall speed of the revascularization process is an important and appropriate measure. It is estimated that for every 30-minute delay in time to revascularization, there is a 10% decrease in the likelihood of a good outcome from endovascular reperfusion therapy. Type of Measure: Process 72

71 CSTK-07 Median Time to Revascularization Continuous Variable Statement: Time (in minutes) from hospital arrival to the start of an intra-arterial (IA) thrombolytic (t-pa) infusion or the first pass of a mechanical reperfusion device in patients with acute ischemic stroke who undergo revascularization therapy Sub-Population: CSTK 2 Ischemic Stroke With IV t-pa, IA t-pa, or MER 73

72 CSTK-07 Included Populations Discharges with an ICD-9-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A, Table 8.1, AND 74

73 CSTK-07 Included Populations Patients with documented thrombolytic infusion therapy (ICD-9-CM Principal or Other Procedure Codes as defined in Appendix A, Table 8.1a), OR Table 8.1a Thrombolytic Agent Procedures Code Shortened Description INJECTION OR INFUSION OF THROMBOLYTIC AGENT 75

74 CSTK-07 Included Populations Patients with documented Mechanical Endovascular Reperfusion Therapy (ICD-9-CM Principal or Other Procedure Codes as defined in Appendix A, Table 8.1b) Table 8.1b Code Mechanical Endovascular Reperfusion Procedures Shortened Description ENDOVASC EMBOL HD/NK VES ENDO REM OBS HD/NECK VES ENDO EMB HD/NK BARE COIL ENDO EM HD/NK, BIOAC COIL 76

75 CSTK-07 Excluded Populations Patients admitted for Elective Carotid Intervention 77

76 CSTK-07 Data Elements Arrival Date Arrival Time Elective Carotid Intervention First Pass of a Mechanical Reperfusion Device First Pass Date First Pass Time 78

77 CSTK-07 Data Elements IA Route of t-pa Administration IA Thrombolytic Initiation IA Thrombolytic Initiation Date IA Thrombolytic Initiation Time Measure specific data elements 79

78 CSTK-07 Algorithm Highlights IA Route of t-pa Administration = No excludes IV t-pa patients, Measure Category B MER patients 2 Patient Paths IA t-pa patients

79 First Pass of a Mechanical Reperfusion Device Definition: First pass (i.e., deployment) of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital. A mechanical reperfusion device is also known as a clot retrieval device. Clot retrieval devices are designed to treat ischemic stroke by removal of the clot from the cerebral artery. Several brand names are used to identify clot retrieval devices which include, Merci, Penumbra, Trevo, and Solataire. For purposes of this data element, pass means mechanical deployment of a clot retrieval device 81

80 First Pass of a Mechanical Reperfusion Device Data Collection Question: Is there documentation in the medical record of the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital? Allowable Values: YES NO 82

81 First Pass of a Mechanical Reperfusion Device Notes for Abstraction: If the first pass of the mechanical reperfusion device at this hospital is unable to be determined from medical record documentation, select No If a diagnostic test report conflicts with other sources documenting the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery, use the documentation found in the diagnostic test report 83

82 First Pass of a Mechanical Reperfusion Device Inclusion Guidelines for Abstraction: Deployment Pass Suggested Data Sources: Consultation notes Diagnostic test reports Operative notes Procedure reports 84

83 First Pass Date / Time Notes for Abstraction: If the date / time of the first pass is unable to be determined from medical record documentation, select UTD The earliest time should be used regardless of how many vessels were treated or which ones were successful vs. unsuccessful 85

84 IA Thrombolytic Initiation Notes for Abstraction: If the data element IA Route of t-pa Administration is "Yes", select "Yes" for IA Thrombolytic Initiation Look for a start time or infusion time for IA thrombolytic If IA thrombolytic initiation is unable to be determined from medical record documentation, select No 86

85 CSTK-07 Algorithm Highlights 2 Patient Paths First Pass Date and Time collected for patients who have A MER procedure IA Thrombolytic Initiation Date and Time collected for patients who get IA t-pa Patients who get IA t-pa and MER have First Pass Date and Time, AND IA Thrombolytic Date and Time

86 CSTK-07 Algorithm Highlights IA t-pa and MER paths joined in IAMER path Algorithm selects the earliest date and time from multiple First Pass and IA Thrombolytic Dates and Times entered

87 CSTK-07 Algorithm Highlights Earliest procedure date and time minus Arrival Date and Arrival Time = Median Time in minutes (i.e., time > 0 min.) Continuous Variable, Measure Category Y

88

89 CSTK-02 mrs at 90 Days Rationale: The Modified Rankin Scale (mrs) is the accepted standard for assessing recovery post-stroke. As such, it has become the most widely used clinical outcome measure for stroke clinical trials. Scores are used to measure the degree of disability or dependence in activities of daily living. Score reliability and reproducibility are improved through use of a structured interview by a trained evaluator. Interviews may be conducted in-person or over the phone. According to guideline recommendations from the American Heart Association/American Stroke Association, standardized interviews to obtain a mrs score should be conducted for acute ischemic stroke patients treated with IV or IA thrombolytic (t-pa) therapy or mechanical endovascular reperfusion therapy at 3 months (90 days); however, recovery may continue well beyond 3 months for many ischemic stroke patients. Type of Measure: Process 91

90 CSTK-02 mrs at 90 Days Denominator: Ischemic stroke patients treated with IV or IA thrombolytic (t-pa) therapy or who undergo mechanical endovascular reperfusion therapy Numerator: Ischemic stroke patients for whom a 90 day ( > 75 days and < 105 days) mrs is obtained via telephone or in-person 92

91 CSTK-02 mrs at 90 Days Denominator: Ischemic stroke patients treated with IV or IA thrombolytic (t-pa) therapy or who undergo mechanical endovascular reperfusion therapy Sub-Population: CSTK 2 Ischemic Stroke With IV t-pa, IA t-pa, or MER 93

92 CSTK-02 Included Populations Denominator: Discharges with an ICD-9-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A, Table 8.1, AND 94

93 CSTK-02 Included Populations Denominator: Patients with documented thrombolytic (IV or IA t-pa) therapy (ICD-9-CM Principal or Other Procedure Codes as defined in Appendix A, Table 8.1a), OR Table 8.1a Thrombolytic Agent Procedures Code Shortened Description INJECTION OR INFUSION OF THROMBOLYTIC AGENT 95

94 CSTK-02 Included Populations Denominator: Patients with documented Mechanical Endovascular Reperfusion Therapy (ICD-9-CM Principal or Other Procedure Codes as defined in Appendix A, Table 8.1b) Table 8.1b Code Mechanical Endovascular Reperfusion Procedures Shortened Description ENDOVASC EMBOL HD/NK VES ENDO REM OBS HD/NECK VES ENDO EMB HD/NK BARE COIL ENDO EM HD/NK, BIOAC COIL 96

95 CSTK-02 Excluded Populations Denominator: Patients admitted for Elective Carotid Intervention Patients who expire during the hospital stay 97

96 CSTK-02 Data Elements Denominator: Discharge Disposition Elective Carotid Intervention Measure specific data elements 98

97 CSTK-02 Algorithm Highlights Patients who expire (= 6) during the hospital stay are excluded

98 CSTK-02 mrs at 90 Days Numerator: Ischemic stroke patients for whom a 90 day ( > 75 days and < 105 days) mrs is obtained via telephone or in-person Included Populations: As above Excluded Populations: None 100

99 CSTK-02 Data Elements Numerator: Modified Rankin Score (mrs) Modified Rankin Score (mrs) Date 101

100 Modified Rankin Score (mrs) Definition: Documentation in the medical record of a Modified Rankin Score (mrs). The Modified Rankin Score (mrs) is a 6 point disability scale with possible scores ranging from 0 to 5. A separate category of 6 is usually added for patients who expire. The Modified Rankin Score (mrs) is the most widely used outcome measure in stroke clinical trials. Standardized interviews to obtain a mrs score are recommended at 3 months (90 days) following hospital discharge 102

101 Modified Rankin Score (mrs) Data Collection Question: What is the patient s Modified Rankin Score (mrs) at 90 days post-discharge? Allowable Values: 0 through 8 6 used for patients who expire after hospital discharge 7 Unable to contact patient/caregiver 8 Modified Rankin Score not performed, OR unable to determine (UTD) from the medical record documentation 103

102 Modified Rankin Score (mrs) Notes for Abstraction: Documented by the physician/apn/pa or nurse (RN), medical assistant, or any individual trained to perform the mrs If more than one value is documented at 90 days, select the highest value If a score range is documented, e.g. 2-3, select the higher value 3 If no mrs is documented, select 8 UTD 104

103 Modified Rankin Score (mrs) Notes for Abstraction: In-person or telephone interviews are acceptable Caregiver may be interviewed if unable to interview the patient Three or more unsuccessful attempts to contact the patient/caregiver, select 7 Patient/caregiver refusal, language barriers without an available translator, HIPPA issues, select 7 105

104 Modified Rankin Score Date Notes for Abstraction: Multiple dates or discrepancy documented, use the earliest date in the 90-day period Dates before 75 days or after 90 days, use the date closest to the 90-day period For patients who expire after hospital discharge, select the date of the interview Unsuccessful attempts, date of the last attempt to contact the patient/caregiver Unable to determine date, select 8 UTD 106

105 CSTK-02 Algorithm Highlights Allowable value 8 only, sends case to Measure Category D mrs Date within 90 days, Measure Category E = Numerator mrs Date outside 90 days, Measure Category D

106

107 New Performance Measure Requirements for CSC Data collection for 8 new CSTK measures effective January 1, 2015 Ongoing data collection for the 8 STK core measures Mandatory data collection requirement for 16 performance measures total 109

108 Data Collection Tools Vendors may be used to submit CSTK data to The Joint Commission Contact your Account Executive to choose a vendor Vendor selection is not linked with STK core vendor Comparion Medical Analytics Midas+ Miosoft Nuance Communications Quantros Quintiles (GWTG)

109 Continuing Education Credit To receive credit, participants must Attest that they have listened to the program in its entirety, and Complete and return the post-course evaluation to The Joint Commission by February 6, 2015 A link to the post-course evaluation will be sent to all registered attendees following this program Certificates of Attendance will be sent via by February 20, 2015 Print a certificate 111

110 Direct questions to

111 Thank You