Performance Measurement Network

Question: If the admitting diagnosis is not stroke, can the case be excluded from STK-4?

81 y.o. female arrived to ED on 12.20.10 @ 21:35 with altered mental status and possible seizure. CT negative Pt. had some left beating nystagmus which resolved with Ativan. Admitted to a regular medical floor with admitting diagnosis of altered mental status and seizure. Mental status continued to deteriorate and patient transferred to ICU on 12.21 and neurology consulted. MRI on 12.21 with acute findings. Physician did not consider tPA due to > 3hrs. since arrival to the hospital. Documentation of why tPa not given was not considered because it was the next day.

When we abstract time of arrival to the ED and Last Date and Time Known Well the timeframe is 45 minutes which made her eligible from a time stand point.

It is clear from the documentation that the physician's primary diagnosis from the ED was seizure activity.

Are there any thoughts related to adding a question similar to PN diagnosed on admission for Stroke patients?

Answer:

The initial stroke patient population is determined by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Principal Diagnosis Code assigned to the patient at discharge (please refer to Appendix A, Tables 8.1 and 8.2 of the Specifications Manual for National Hospital Inpatient Quality Measures for the complete list of stroke codes). The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” The admitting diagnosis and principal diagnosis assigned at discharge may not be the same diagnosis.

Some stroke measures, specifically STK-1: VTE Prophylaxis, STK-5: Antithrombotic Therapy By End of Hospital Day 2, and STK-4: Thrombolytic Therapy, are time dependent as recommended by the clinical practice guidelines supporting these measures. These measures address acute medical intervention and early patient management, and reflect the quality of care provided to the patient during the hospital stay. Patients presenting to the hospital with warning signs and symptoms of stroke should be evaluated for stroke and treated accordingly until a diagnosis of stroke is ruled out. A working diagnosis exclusion will not be added to STK-4.

All of the above measures do exclude cases from the measure population when there is a legitimate reason for not providing treatment documented in the medical record by the MD/APN/PA or pharmacist, e.g."t-PA not indicated due to seizure activity". Reason documentation must be within the timeframe for thrombolytic administration.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical, Related Manual - Data Quality Manual
Related documents: STK-04, thrombolytic therapy
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