Performance Measurement Network
Home » Question regarding the new STK OP 1 Measure

Question: Question regarding the new STK OP 1 Measure

In a situation where you have free standing EDs under the same CCN that is a the PSC, should the STK OP 1 measure be all encompassing?

For reporting purposes, do we include the free standing EDs OR just report our ED within our PSC? We know this is a very new measure, but we were hoping to seek some advice from you. We have two free standing EDs that have the same CCN as the Primary Stroke Center.

If we are to report the free standing EDs separately: • Is this something that is required from TJC? • If so, how is it suggested that we should separate out this measure when the EDs are operating under the same CCN? • Does this measure only apply to those sites that are certification via The Joint Commission such as PSC/CSC/ASRH? (the two free standing EDs are not ASRH )

Answer:

Tabitha, This question has come up with implementation of CSTK-01 because PSCs give more IV t-PA than CSCs.

Since "Arrival Time" is used in many CSTK measures not only CSTK-01, it is important to abstract the "Arrival Time" at the hospital that is reporting the measure so that additional minutes are not added to measures with strict time frames, e.g., door to groin puncture.

For your scenario, we suggest abstracting as follows:

"ICD-10-PCS Principal / Other Procedure Time(s)" For ischemic stroke patients who receive intravenous (IV) alteplase (t-PA) at your hospital’s satellite/free-standing ED prior to transfer to the hospital and there is one medical record for the care provided at both facilities, use the Arrival Time at the hospital for the ICD-10-PCS Principal/Other Procedure Time(s).

"Initial NIHSS Score Time" For ischemic stroke patients who receive intravenous (IV) alteplase (t-PA) at your hospital’s satellite/free-standing ED prior to transfer to the hospital and there is one medical record for the care provided at both facilities, use the Arrival Time at the hospital for scores documented before IV t-PA initiation.

This should allow the case to flow through and still maintain the measure intent. Updates to these data elements will be published with the next version of the specifications manual.

Thank you for your patience.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-OP, STK-OP1
Manual: Current Manual (current data collection period; prior to data transmission)
File:

Copyright © by the contributing authors. All material on this collaboration platform is the property of the contributing authors.
Ideas, requests, problems regarding Performance Measurement Network? Send feedback