Performance Measurement Network

Question: First NIHSS performed days after admission

For the data element " Is there documentation that an initial NIHSS performed at this hospital", is there any time frame associated with the term initial. I have a patient who was here several days before an NIHSS was performed. Should I answer "yes" to this question? The term "Initial" is confusing to me, and I can't find any clarification in the rule for a time frame. Another patient only had one NIHSS performed, and that was at discharge several days later.


Nancy, Please refer to the CSTK-01 MIF in the specifications manual. A NIHSS score should be done and documented within 12 hours of hospital arrival for patients who do not receive a reperfusion therapy. If the first NIHSS done at your hospital was later than 12 hours (720 min) post arrival, the Timing III calculation (i.e., Initial NIHSS Score Date and Initial NIHSS Score Time minus the Arrival Date and Arrival Time) in the measure algorithm will send the case to the 'D' bucket and it fails.

CSTK-01 Numerator Statement: Ischemic stroke patients for whom a NIHSS score is performed prior to any acute recanalization therapy in patients undergoing recanalization therapy and documented in the medical record, OR documented within 12 hours of hospital arrival for patients who do not undergo recanalization therapy.

Hope this clarifies for you. Thank you for your inquiry.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: CSTK-01, CSTK-01 Initial NIHSS,
Manual: Current Manual (current data collection period; prior to data transmission)

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