Performance Measurement Network

Question: Stroke after admission-arrival to skin puncture CSTK -09

I recently entered a patient into GWTG who suffered a stroke after arrival to the hospital. She had IA tPA. Her arrival to skin puncture time remains "included" on the report, and it shouldn't because she's an inpatient stroke. I queried GWTG and they couldn't help me. Does CSTK-09 measure arrival times for everyone, including inpatients? If so, is this new, because it never happened before. In addition, was there ever a parameter on CSTK-01, where cases were excluded if Last Known Well >12 hours? I have a case, included in my report this month, where NIHSS not documented within 12 hrs, but last known well was 3 weeks prior. Neither case is making common sense to me, please advise. Thank you


Denise, The Joint Commission stroke measures use ICD-10-CM Principal Diagnosis Codes for ischemic and hemorrhagic stroke to include appropriate cases in the Initial Patient Population. The concept of stroke diagnosis is not collected for TJC stroke measures. Clinical diagnosis is collected for GWTG only.

Last Known Well is not collected for CSTK-01. There is no exclusion for cases with LKW after hospital arrival.

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

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

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