stroke core measures 202110 marca 2023
TJC Comprehensive Stroke Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 3. STK-OP-1e Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible6. CSTK-05 Hemorrhagic Transformation, 1. The American Medical Association reserves all rights to approve any license with any Federal agency. There is a great demand today for accurate, useful information on health care quality that can inform the decisions of consumers, employers, physicians and other clinicians, and policymakers. 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. CMS is already using measures from the each of the core sets. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. Measure 6a is new and is being pilot tested in 2009. lock In addition, stroke rehabilitation incorporates prevention and treatment of medical and mental health complications such as aspiration pneumonia, soft-tissue contractures, decubitus ulcers, infection, deep vein thrombosis (DVT), malnourishment, and depression. Since the program's start in 2003, over 2,000hospitals have entered more than 5million patient records into the Get With The Guidelines- Stroke database. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. 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. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> m/P]H(ZVk[/ "+TPy9|9J1C0.ZOK_i@"$B'r~-("tNZmO}cv!eB Improve Maternal Outcomes at Your Health Care Facility, Accreditation Standards & Resource Center, Ambulatory Health Care: 2023 National Patient Safety Goals, Assisted Living Community: 2023 National Patient Safety Goals, Behavioral Health Care and Human Services: 2023 National Patient Safety Goals, Critical Access Hospital: 2023 National Patient Safety Goals, Home Care: 2023 National Patient Safety Goals, Hospital: 2023 National Patient Safety Goals, Laboratory Services: 2023 National Patient Safety Goals, Nursing Care Center: 2023 National Patient Safety Goals, Office-Based Surgery: 2023 National Patient Safety Goals, The Term Licensed Independent Practitioner Eliminated, Updates to the Patient Blood Management Certification Program Requirements, New Assisted Living Community Accreditation Memory Care Certification Option, Health Care Equity Standard Elevated to National Patient Safety Goal, New and Revised Emergency Management Standards, New Health Care Equity Certification Program, Updates to the Advanced Disease-Specific Care Certification for Inpatient Diabetes Care, Updates to the Assisted Living Community Accreditation Requirements, Updates to the Comprehensive Cardiac Center Certification Program, Health Care Workforce Safety and Well-Being, Report a Patient Safety Concern or Complaint, The Joint Commission Stands for Racial Justice and Equity, The Joint Commission Journal on Quality and Patient Safety, John M. Eisenberg Patient Safety and Quality Award, Bernard J. 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. A hospitals hemorrhagic stroke patient population size is 200 cases during the second quarter. See our editorial policies and staff. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. Here I have broken it into the inpatient measure set and the outpatient measure set. 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. %PDF-1.4 % All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. <> You receive one consultant that you can call anytime with questions or concerns. . Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9. 690 0 obj <>stream 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. A hospitals Ischemic sub-population is 316 during January. The following table identifies the population . STK-5 Antithrombotic Therapy By End of Hospital Day Two16. But hospitals see benefits as well. 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 Return to Clinical Data Processing Flow in the Data Processing section. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. To search the historic measure inventory, enter one or more terms in the search box and hit enter or click the search button. STK-4 Thrombolytic Therapy7. At the beginning of 2020, The Joint Commission switched over to the Direct Data Submission Platform (DDSP). 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. The numerator options included in this Monthly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 228 during March. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. Much like we saw how cases fall into their respective sub-populations with CSTK, cases for STK use the same criteria when determining which sub-population a case will qualify for. Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. <> For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form(PDF). Using the monthly sampling table for the Ischemic 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). All rights reserved. Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second 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. 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#. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 5. 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. The most common signs and symptoms of HF are shortness of breath on exertion; orthopnea; weight gain with edema in the feet, legs, or lower back; fatigue; and weakness. Request Appointment Quality and Mayo Clinic Arizona Florida Minnesota Event reporting Quality measures Quality rankings Stroke Core Measure Loading chart. Each certification may require your hospital to submit one or more of the five measure sets we reviewed above. REMINDER: Stroke is now a Core Measure for CMS!!! We aim to determine feasibility of implementing stroke core measures and training through blended learning modules in resource poor countries to improve stroke outcomes. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> STK-OP-1i Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, 3. For the purposes of this blog, since we are focusing specifically on stroke measures, there is only one stroke measure that is used for Accreditation purposes by both CMS and TJC: OP-23. 2021 94.5% (307/325) 2020 91.7% (275/300) STK-2 2022 100.0% (117/117) . 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%. STK-6 Discharged on Statin Medication12. This means the patient passed every measure they qualified for. Hospitals now have one place to submit both chart-abstracted and eCQM data. decreased providers collection burden and cost. This measure set is applicable to patients with diagnoses of ischemic stroke and hemorrhagic stroke, and TIA. endstream endobj startxref Get more information about cookies and how you can refuse them by clicking on the learn more button below. Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI : Scan Interpretation Within 45 minutes of ED Arrival: 2012 . Clinical practice guidelines for the prevention of VTE recommend the use of preventive therapies in at-risk patients. Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Set the Initial Patient Population Reject Case Flag to equal Yes. STK-5 Antithrombotic Therapy By End of Hospital Day Two8. <> The next measure set we review is abbreviated ASR-IP/OP. CPT only copyright 2019 American Medical Association. Medisolv can help you along the way. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. 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. This Agreement will terminate upon notice if you violate its terms. 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 All rights reserved. stroke patients receiving IV t-PA at your hospital who are treated within 45 minutes after triage (ED arrival). The required sample size for the CSTK-01 measure is a minimum of 42 cases for the month (28 cases from Table 4 plus 14 cases from Table 5 equals 42). Find evidence-based sources on preventing infections in clinical settings. The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. Closed on Sundays. Stroke Core Measures Stroke 'core measures' are critical steps in a patient's hospital stay that have been established based on outcomes. Measure requirements are often not aligned among payers, which has resulted in confusion and complexity for reporting providers. If the ICD-10-CM Principal Diagnosis Code is on Table 8.1, the patient is in the first Ischemic Stroke sub-population and is eligible to be sampled for the first STK sub-population. %PDF-1.5 Return to Clinical Data Processing Flow in the Data Processing section. CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only, 3. 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. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). 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. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Here is a diagram that outlines the submission differences. STK-5 Antithrombotic Therapy By End of Hospital Day Two11. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. 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.