Performance Measurement Network

Question: CSTK 02, 05, and 06 Measures

Several questions regarding the CSTK measures:

CSTK 2: If we make every attempt to reach the patient but are unable to make contact (r/t disconnected/incorrect phone numbers, etc., if we document why we were unable to reach the patient, will we still be compliant with this measure?

CSTK 5: Are patients treated with IV tpa at another facility and transferred into this facility included in this population?

CSTK 6: For patients that are unable to swallow, and the physicians do not feel that it is appropriate to place a feeding tube, if there is documentation as to why the feeding tube wasn't placed, and thus why the patient didn't receive the Nimodipine within 24 hours, would we still be compliant with this measure?)

Answer:

Q1: CSTK-02 - If documentation reflects that after 3 attempts to contact the patient/caregiver, the mRS could not be obtained because attempts to contact the patient/caregiver were unsuccessful, select allowable value '7' for the data element "Modified Rankin Score". The case will be excluded.

Q2: CSTK-05. Patients are included in the denominator if the intervention was performed at your hospital. To include the case in the denominator, the case must have a principal or other procedure code for thrombolytic therapy (Table 8.1a ICD-9 code 99.10 or mechanical endovascular reperfusion therapy (Table 8.1b). Also, the definition of the data element "IV Thrombolytic Initiation Time" is i.e.,"The military time for which IV thrombolytic therapy was initiated at this hospital".

If IV t-PA is given at a transferring hospital, and IA t-PA or MER done at your hospital, the case is in the denominator based on the IA t-PA or MER therapy that was performed. Enter the IA t-PA or MER Date and Time at your hospital. The case will flow down the IAMER path and bypass the IV Thrombolytic Initiation Date / Time data elements in the IVO path. If IV t-PA, IA t-PA and/or MER were all done at your hospital, the case will still flow down the IAMER path because that date and time occurs before IVO in the algorithm flow logic.

If IV t-PA only at your hospital and no further intervention at your hospital, the case should have procedure code 99.10 and will flow down the IVO path because "NO" was selected for "IA Route of t-PA Administration". If IV t-PA at a transferring hospital and no further intervention at your hospital, the case should not be included in the denominator population based on assigned procedure codes.

Q3: CSTK-06 - This measure has a data element "Reason for Not Administering Nimodipine Treatment" (See Notes for Abstraction in the data element definition). Documentation that the patient is NPO or has a NGT without mention of Nimodipine is insufficient, select "NO". An order for NPO alone does not count as a reason. The MD/APN/PA or pharmacist must explicitly document a reason and mention nimodipine, e.g., "will not start nimodipine because NPO". Also a hold or discontinuation of nimodipine during the 24 hour timeframe counts as a reason or a hold/discontinuation of all PO meds if nimodipine was on order at the time of the notation.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: CSTK-01, CSTK-02, CSTK-05, CSTK-06,
File:

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