Performance Measurement Network

Question: Are patients who have ischemic stroke occured after hospital arrival included in CSTK-01 population

CSTK-01 is now being collected by primary stroke centers. I need clarification of patients included/excluded. I have reviewed specifications manual for JC National Quality measures (v2018B and could not clearly find the answer to my question.

Are patients who have an ischemic stroke occurred after hospital arrival included in this measure? If so, how can clinicians document NIH within 12 hours of arrival if not admitted for stroke. )


The clinical lead for the stroke measures is currently out of the office. You will receive a response to your inquiry as soon as possible upon her return. Thank you for your patience.

ANSWER: Ashley, There is no exclusion for patients diagnosed with ischemic stroke after hospital arrival, e.g., "in-house stroke". If the patient was assigned an ICD-10-CM Principal Diagnosis Code for ischemic stroke, then ischemic stroke was the reason for the patient's admission to the hospital per the World Health Organization definition used in the measure specifications. CSTK-01 clock starts with the patient's arrival time at the hospital.

For the list of populations excluded from the CSTK-01 denominator population, please refer to the CSTK-01 Measure Information Form (MIF) in the current version of the specifications manual. Thank you.

Denominator Statement: Ischemic stroke patients.

Included Populations: Discharges with ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A, Table 8.1 for ICD-10 codes

Excluded Populations: Patients less than 18 years of age Patients who have a Length of Stay > 120 days Patients with Comfort Measures Only documented on the day of or day after hospital arrival Patients admitted for Elective Carotid Intervention Patients who do not undergo recanalization therapy and are discharged within 12 hours of arrival at this hospital)

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

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