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 treatment2. A hospitals ischemic stroke patient population size is 392 cases during the second quarter. Forty states reported at least half (16) of the Adult Core Set measures for FFY 2019. Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. STK-OP-1 Door to Transfer to Another Hospital, 1. Understanding Stroke Measure Sets - f.hubspotusercontent30.net Approximately 2-4% of patients with stroke have their event while hospitalized for another condition, with almost one half resulting from a vascular procedure. U.S. Government Rights Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 14 cases for the month. 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. Create your baseline by entering 30 records into the Patient Management Tool. 1 0 obj CSM Chart Abstracted Measures for Certification. Commercial health plans are rolling out the core measures as part of their contract cycle. Stroke Core Stroke Measures As a Certified Stroke Center the stroke committee would like to provide physicians with updates on how we are performing on the stroke performance and quality measures. These updated core sets are a result of months of consensus-based review and deliberation among the groups 75+ multi-stakeholder member organizations, evaluating hundreds of existing quality measures against the CQMCs rigorous criteria. 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-10 Assessed for Rehabilitation. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. It is important to always refer to the latest edition. . A hospital may choose to use a larger sample size than is required. 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 . 2021; 96:e1812-e1822 . Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 150 cases for the quarter. Disclaimer of Warranties and Liabilities. Core measures are based on the most common condition's hospitals see, such as acute myocardial infarction (AMI), heart failure (HF), pneumonia, surgical care, children's asthma care, venous thromboembolism (VTE), stroke, and more. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. I hope this high-level overview was helpful and can be a reference for you. 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. There are no Stroke eCQMs applicable or available for Certification purposes. Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. STK-8 Stroke Education13. This Agreement will terminate upon notice if you violate its terms. Using the monthly sampling table for the Ischemic sub-population, the sample size is less than the minimum required monthly sample size, so 100% of this sub-population is sampled. All rights reserved. % The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. >ob=AOtVt. A hospitals hemorrhagic stroke patient population size is 392 cases during the second quarter. Nonvalvular atrial fibrillation is a common arrhythmia and an important risk factor for stroke. The Hemorrhagic sub-population is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. 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. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 1-800-AHA-USA-1 Research projects are hypothesis-driven studies that are developed into manuscripts suitable for peer-reviewed publication. .gov 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. Official websites use .govA STK-4 Thrombolytic Therapy7. We help troubleshoot technical and clinical issues to improve your measures. 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 STK-OP-1a Overall Rate (Not Reported2. LqV)%0w#lP.s9XsG58gX'5L S AP*=;%)e0J9_T-NXC4*~bTdsSFnde#;nOOyOqsi]qQV/Fb3KtK. Heres a link to TJCs full program comparison sheet with guidelines of certification requirements. Mayo Clinic is a nonprofit organization and proceeds from Web advertising help support our mission. The AMA is a third party beneficiary to this Agreement. Learn more about the communities and organizations we serve. Monday - Friday: 7 a.m. 7 p.m. CT stream STK-1 Venous Thromboembolism (VTE Prophylaxis)7. Chart-abstracted measures specificationsScreen Reader Text. Domain-specific outcomes for stroke clinical trials: what the modified Rankin isn't ranking. All rights reserved. STK-OP-1b Hemorrhagic Strok3. Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 392 during the first quarter. CMIT searches all fields in the inventory and is not case-sensitive. ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. Anticoagulation therapy is a course of drug therapy in which medications are administered to a patient to slow the rate at which the patient's blood clots. Comprehensive Stroke (CSTK) (v2021A1) Home Comprehensive Stroke (CSTK) Comprehensive Stroke (CSTK) On this page: Comprehensive Stroke (CSTK) Initial Patient Population Monthly Sampling Sample Size Examples Set Measures General Data Elements Algorithm Output Data Elements Measure Set Specific Data Elements Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 17 cases are sampled. A hospitals ischemic stroke patient population size is 70 cases during March. CPT is a registered trademark of the American Medical Association. Using the quarterly sampling table for the Hemorrhagic sub-population, the sample size required is 20% of this sub-population, or 79 cases for the quarter (twenty percent of 392 equals 78.4 rounded up to the next whole number equals 79). The following are Stroke chart abstracted measures used by The Joint Commission. For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form(PDF). There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. STK-OP-1g Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**8. stream 2021 94.5% (307/325) 2020 91.7% (275/300) STK-2 2022 100.0% (117/117) . The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. Patients admitted to the hospital for inpatient acute care are included in the CSTK-2 Ischemic Stroke With IV t-PA, IA t-PA, or MER subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 8.1 AND ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 8.1a OR Table 8.1b, a Patient Age (Admission Date Birthdate) 18 years and a Length of Stay (Discharge Date - Admission Date) 120 days. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. Find more information on our content editorial process. 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. 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. 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. This means the patient passed every measure they qualified for. Eleven (11) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. Sign up to get the latest information about your choice of CMS topics. The median number of Adult Core Set measures reported by states is 22.5 measures for FFY 2019, up from 20 measures reported for FFY 2018 and 17 measures for FFY 2017. May 2021 Measure ID# Measure Short Name Measure Description STK-1 Venous Thromboembolism (VTE) This measure captures the proportion of ischemic or hemorrhagic Prophylaxis stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission. endobj An injection of TPA is usually given through a vein in the arm within the first three hours. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. You can decide how often to receive updates. 7272 Greenville Ave. 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. 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. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. An official website of the United States government STK-1 Venous Thromboembolism (VTE Prophylaxis)12. Hospital Outpatient Quality Measure Stroke. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. 2 0 obj 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. The annual Acute Care Hospital Quality Improvement Program Measures reference guide provides a comparison of measures for five Centers for Medicare & Medicaid Services (CMS) acute care hospital quality improvement programs, including the: Hospital IQR Program Hospital Value-Based Purchasing (VBP) Program Promoting Interoperability Program In addition, 36 states reported more Adult Core Set measures for FFY 2019 than for FFY 2018. We develop and implement measures for accountability and quality improvement. ASR-IP-3: Discharged on Antithrombotic Therapy4. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 20% of this subpopulation or 26 cases for the month (20% of 129 equals 25.8 rounded to the next highest whole number equals 26). 690 0 obj <>stream 4 0 obj Unauthorized use prohibited. endstream endobj startxref Refine processes and protocols to ensure they are in line with the guidelines. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Comprehensive Stroke Arrival Time to Skin Puncture, Comprehensive Stroke Post Thrombolysis Revascularization Rate, Comprehensive Stroke Timeliness of IV Thrombolytic Therapy, Advertising and sponsorship opportunities, Percent of ischemic and hemorrhagic stroke patients who received venous thromboembolism (VTE) prophylaxis the day of or the day after hospital admission. They also could require other measures. These core measure sets are a major step forward for alignment of quality measures between public and private payers and provides a framework upon which future efforts can be based. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. STK-5 Antithrombotic Therapy By End of Hospital Day Two16. Brainstorm with your team to find ways to improve your hospital's treatment rates. CSTK-09 Arrival Time to Skin Puncture, 1. The AMA does not directly or indirectly practice medicine or dispense medical services. Monthly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 228 during March. 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). Part 1: A review of the different stroke measure sets. Use the PMT benchmarking reports to identify areas for improvement and refine processes and protocols to ensure they are in line with the guidelines. Calculate the Length of Stay. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)7. CSTK-05 Hemorrhagic Transformation, 1. Test your ideas. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. Measure 6a is new and is being pilot tested in 2009. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 50 cases for the month. Learn how working with the Joint Commission benefits your organization and community. A hospitals Ischemic sub-population is 5 patients during the first quarter. ASR-OP-1 Thrombolytic Therapy (Drip and Ship)5. The AMA does not directly or indirectly practice medicine or dispense medical services. 2023 American Heart Association, Inc. All rights reserved. The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. 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). Time from symptom onset to stroke alert is delayed in in-hospital stroke. x[6 >tK(E4.z~bK[K6IL[Ev9$g8oon_G|&"JLEE DFowJEM/7^G7Zt]kv\}{\](6t~fFKHVY4#o}Q1ps 2)bO}eYOcfY[7YO_b;x%k)ZJE,Tx[p53^\BH\T,uFN'gI8JP^fD*VbIgWb 4*nO4>nEHlE<4VujSs.i[_i]@gjBq?yrY5r>||x\n#bi\O#_5mHXG_@0-`=[05L$Ae[BvzWR?y'1XV%^m#. A hospitals ischemic stroke patient population size is 200 patients during March. An IV injection of recombinant tissue plasminogen activator (TPA) also called alteplase (Activase) or tenecteplase (TNKase) is the gold standard treatment for ischemic stroke. "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. 2023 Medisolv, Inc. All Rights Reserved. STK-OP-1i Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, 3. Pets and Your Health / Healthy Bond for Life, La Iniciativa Nacional de Control de la Hipertensin, Contact your local Get With The Guidelines, Get With The Guidelines Data Request Form. 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. Each certification may require your hospital to submit one or more of the five measure sets we reviewed above. 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. Twenty (20) ischemic stroke patients had a procedure for thrombolysis or mechanical clot removal. a set of re-specified measures in 2019, which were updated in 2021. The STK Initial Patient Population sizes for a hospital are 392 and 5 patients respectively per the sub-populations for the quarter. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. ( Start STK Initial Patient Population logic sub-routine. The Core Quality Measure Collaborative, led by the Americas Health Insurance Plans (AHIP) and its member plans Chief Medical Officers, leaders from CMS and the National Quality Forum (NQF), as well as national physician organizations, employers and consumers, worked hard to reach consensus on core performance measures. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 75 cases for the quarter. endobj 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]. 1 0 obj A hospitals ischemic stroke patient population size is 295 cases during March. Drive performance improvement using our new business intelligence tools. We can make a difference on your journey to provide consistently excellent care for each and every patient. 4 0 obj decreased providers collection burden and cost. A hospitals ischemic stroke patient population size is 200 patients during the second quarter. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the month. 1 0 obj STK-8 Stroke Education10. By not making a selection you will be agreeing to the use of our cookies. 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. 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). CMS will use these mortality measures, which it reports under the Clinical Care domain, in the FY 2019 program. Comprehensive Core Stroke Measures were developed for the management of both ischemic and hemorrhagic stroke patients in hospitals equipped with clinical expertise, infrastructure, and specialized neurointerventional and imaging services needed to provide a higher level of stroke care. CSTK-05 Hemorrhagic Transformation, 1. *{o7@FNhR/ Information in this course pertains to 01/1/13 - 12/31/13, version 4.2 of the Specifications Manual. 0 Measures for TJC Acute Stroke Ready Center Certification, 1. 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. >0SPJ*@6W/rq+ERY_X&14>k( This is increasingly important as the health care system moves towards value-based reimbursement models. Here are some resources to help you get started: JoAnne Marino is a Registered Nurse that is currently working as a Senior Clinical Consultant for Medisolv helping clients with the ENCOR Hospital Abstracted Measures. m/P]H(ZVk[/ "+TPy9|9J1C0.ZOK_i@"$B'r~-("tNZmO}cv!eB The psychometric properties of the measures are reviewed using a modified EDGE (Evidence Database to Guide Effectiveness) template (a format recommended by the APTA EDGE task force). The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers. All rights reserved. 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 QualityResearch@heart.org. The next measure set we review is abbreviated ASR-IP/OP. CPT only copyright 2019 American Medical Association. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% of the Initial Patient Population is required, Patient level data must be processed in order to submit your aggregate data. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 5. Honestly though Stroke Outpatient versus Outpatient Stroke. 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. Repeat steps 8 and 9 until your team is happy with your treatment rates and your hospital is eligible for. website belongs to an official government organization in the United States. Mayo Clinic does not endorse any of the third party products and services advertised. The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. Ready to get started with CMIT 2.0? TARGET: STROKE MEASURE CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival10. Percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. This content does not have an English version. Measure Type: InpatientNumber of Measures Included: 3 process measuresCertification Requirement: The Joint Commissions Disease-Specific Care Certification, Measure Type: OutpatientNumber of Measures Included: 2 process measuresCertification Requirement: The Joint Commissions Disease-Specific Care Certification, Door to Transfer to Another Hospital**RETIRED Effective July 1, 2021**, Note: All Joint Commission certified acute stroke ready hospitals, as well as those seeking initial certification, will be required to collect the STK-OP-1 Door to Transfer to Another Hospital measure for discharges on and after July 1, 2021. Core Measure Data as of 3/2/2022. In addition, TJC established the Certification Measure Information Process (CMIP) tool where hospitals must manually enter their certification data for the program certifications we reviewed above (ASR, PSC, TSC and CSC).
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