Specifications Manual for Joint Commission National Quality Measures (v2017B2)

Release Notes:
Measure Information Form
Version 2017B2


**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Comprehensive Stroke(CSTK)

Set Measure ID: CSTK-03

Set Measure ID Performance Measure Name
CSTK-03a Hunt and Hess Scale Performed for SAH Patients
CSTK-03b ICH Score Performed for ICH Patients

Performance Measure Name: Severity Measurement Performed for SAH and ICH Patients (Overall Rate)

Description: Subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) stroke patients for whom a severity measurement (i.e., Hunt and Hess Scale for SAH patients or ICH Score for ICH patients) is performed prior to surgical intervention (e.g. clipping, coiling, or any surgical intervention) in patients undergoing surgical intervention and documented in the medical record; OR documented within 6 hours of arrival at the hospital emergency department for patients who do not undergo surgical intervention.

CSTK-03    SAH and ICH stroke patients for whom a severity measurement is performed prior to surgical intervention in patients undergoing surgical intervention and documented in the medical record; OR documented within 6 hours of hospital arrival for patients who do not undergo surgical intervention.

CSTK-03a   SAH stroke patients for whom a severity measurement is performed prior to surgical intervention in patients undergoing surgical intervention and documented in the medical record; OR documented within 6 hours of hospital arrival for patients who do not undergo surgical intervention.

CSTK-03b   ICH stroke patients for whom a severity measurement is performed prior to surgical intervention in patients undergoing surgical intervention and documented in the medical record; OR documented within 6 hours of hospital arrival for patients who do not undergo surgical intervention.

The CSTK-03 measure is reported as an overall rate which includes SAH and ICH stroke patients for whom a severity measurement is performed prior to surgical intervention in patients undergoing surgical intervention and documented in the medical record; OR documented within 6 hours of hospital arrival for patients who do not undergo surgical intervention; CSTK-03a and CSTK-03b are subsets of the overall rate, and stratified by the type of stroke patient.

Rationale: Subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) are medical emergencies requiring rapid diagnosis and assessment. Early deterioration is common in the first few hours after onset, and associated with increased mortality rates of > 75% compared to 30-day mortality rates of 35%-52%. More than half of all deaths from these conditions occur within the first two days. According to the American Heart Association/American Stroke Association, the severity of SAHs should be documented with the Hunt and Hess Scale, and the severity of ICHs should be documented with ICH score to capture the clinical state of the patient. The severity of initial neurological injury should be determined and documented in the emergency department because it is a useful predictor of outcome and helpful in planning future care with family and physicians. For both severity methodologies, higher scores are associated with increased mortality.

Type of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement:
CSTK-03:   The number of SAH and ICH stroke patients for whom a severity measurement is performed prior to surgical intervention in patients undergoing surgical intervention and documented in the medical record; OR documented within 6 hours of hospital arrival for patients who do not undergo surgical intervention.

CSTK-03a:   The number of SAH patients for whom a Hunt and Hess Scale is performed prior to surgical intervention in patients undergoing surgical intervention and documented in the medical record; OR documented within 6 hours of hospital arrival for patients who do not undergo surgical intervention.

CSTK-03b:   The number of ICH stroke patients for whom an ICH Score is performed prior to surgical intervention in patients undergoing surgical intervention and documented in the medical record; OR documented within 6 hours of hospital arrival for patients who do not undergo surgical intervention.

Included Populations: As above

Excluded Populations: None

Data Elements:

Data Elements By Measure
CSTK-03 CSTK-03a CSTK-03b
Arrival Date Arrival Date Arrival Date
Arrival Time Arrival Time Arrival Time
Initial Hunt and Hess Scale Date Initial Hunt and Hess Scale Date Initial ICH Score Date
Initial Hunt and Hess Scale Performed Initial Hunt and Hess Scale Performed Initial ICH Score Performed
Initial Hunt and Hess Scale Time Initial Hunt and Hess Scale Time Initial ICH Score Time
Initial ICH Score Date    
Initial ICH Score Performed    
Initial ICH Score Time    

Denominator Statement: SAH and ICH stroke patients

Included Populations: Discharges with ICD-10-CM Principal Diagnosis Code for hemorrhagic stroke as defined in Appendix A, Table 8.2 for ICD-10 codes (i.e., Table 8.2a and Table 8.2b) with or without aneurysm repair procedure (ICD-10-PCS Principal or Other Procedure Code as defined in Appendix A, Table 8.2d for ICD-10 codes) or surgical intervention procedure (ICD-10-PCS Principal or Other Procedure Code as defined in Appendix A, Table 8.2e 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
  • Non-surgical patients discharged within 6 hours of arrival at this hospital
  • Patients with admitting diagnosis of traumatic brain injury (TBI), unruptured arteriovenous malformation (AVM), and non-traumatic subdural hematoma (ICD-10-CM Other Diagnosis Codes as defined in Appendix A, Table 8.2f for ICD-10 codes)

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: Hospitals may wish to identify those patients that did not receive a severity assessment within the specified timeframe(s), or received a severity assessment that did not match their diagnosis, or both, so that efforts can be directed toward improving care.

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References: 1.  Broderick J, Connolly ES, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M, Morgenstern L, Ogilvy CS, Vespa P, and Zuccarello M. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline as an educational toold for neurologists. Stroke. 2007;38:2001-2023.

2.  Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guidelines for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43:1-27.

3.  Hemphill JC III, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald L, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the management of spontaneous intracerebral hemorrhage:a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:1-29.

4.  Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968;28:14-20.

5.  Hunt WE, Kosnik EJ. Timing and perioperative care in intracranial aneurysm surgery. Clin Neurosurg. 1974;21:79-89.

6.  Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C, Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:862-63.

7.  Matchett SC, Castaldo J, Wasser TE, Baker K, Mathiesen C, and Rodgers J. Predicting mortality after intracerebral hemorrhage: comparison of scoring systems and influence of withdrawal of care. J Stroke Cerebrovasc Dis. 2006 Jul-Aug;15(4):144-50.

8.  Morgastern LB, Hemphill JC III, Anderson C, Becker K, Broderick JP, Connolly ES Jr, Greenberg SM, Huang JN, Macdonald RL, Messé SR, Mitchell PH, Selim M, Tamargo RJ; and on behalf of the American Heart Association Stroke Council and Council on Cardiovascular Nursing. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41:2108-2129.

9.  Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales: a systematic review. Neurocritical Care. 2005;2:110-118.

Measure Algorithm:
CSTK-03_pg1.jpg v7 CSTK-03_pg2.jpg v7 CSTK-03_pg3.jpg v7 CSTK-03_pg4.jpg v5 CSTK-03_pg5.jpg v8 CSTK-03_pg6.jpg v4

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Measure Information Form CSTK-03
Specifications Manual for Joint Commission National Quality Measures (v2017B2)
Discharges 01-01-18 (1Q18) through 06-30-18 (2Q18)
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