Specifications Manual for Joint Commission National Quality Measures (v2019A)

Release Notes:
Measure Information Form
Version 2019A

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

Measure Information Form

Measure Set: Comprehensive Stroke (CSTK)

Set Measure ID: CSTK-01

Performance Measure Name: National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)

Description: Ischemic stroke patients for whom an initial NIHSS score is performed prior to any acute recanalization therapy (i.e., IV alteplase therapy, or IA alteplase therapy, or mechanical endovascular reperfusion therapy) in patients undergoing recanalization therapy and documented in the medical record, OR documented within 12 hours of arrival at the hospital emergency department for patients who do not undergo recanalization therapy.

Rationale: A neurological examination of all patients presenting to the hospital emergency department with warning signs and symptoms of stroke should be a top priority and performed in a timely fashion. Use of a standardized stroke scale or scoring tool ensures that the major components of the neurological examination are evaluated. Clinical practice guidelines from the American Heart Association/American Stroke Association recommend The National Institutes of Health Stroke Scale (NIHSS) as the preferred scoring tool for this purpose. Scores obtained aid in the initial diagnosis of the patient, facilitate communication among healthcare professionals, and identify patient eligibility for various interventions and the potential for complications.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients for whom a NIHSS score is performed prior to any acute recanalization therapy in patients undergoing recanalization therapy and documented in the medical record, OR documented within 12 hours of hospital arrival for patients who do not undergo recanalization therapy.
Included Populations:
  • Patients with documented thrombolytic (IV or IA alteplase) therapy (ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 8.1a for ICD-10 codes), OR
  • Patients with documented Mechanical Endovascular Reperfusion Therapy (ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 8.1b for ICD-10 codes)

Excluded Populations: None

Data Elements:

Denominator Statement: Ischemic stroke patients.
Included Populations:
  • Discharges with ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A, Table 8.1 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
  • Patients admitted for Elective Carotid Intervention
  • Patients who do not undergo recanalization therapy and are discharged within 12 hours of arrival at this hospital

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: None

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. Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks E. Guidelines for the Early Management of Adults with Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007;38:1664-1666.


2. Cote R, Hachinski VC, Shurell BL, Norris JW, Wolfson C. The Canadian Neurological Scale: a preliminary study in acute stroke. Stroke. 1986; 17:731-737.


3. Goldstein LB, Samsa GP. Reliability of the National Institutes of Health Stroke Scale: extension to non-neurologists in the context of a clinical trial. Stroke. 1997;28:307-310.

4.  Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:32-36.


5. Kothari KU, Brott T, Broderick JP, Hamilton CA. Emergency physicians: accuracy in the diagnosis of stroke. Stroke. 1995;26:2238-2241.


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;42:857.


7. Morgenstern LB, Lisabeth LD, Mecozzi AC, Smith MA, Longwell PJ, McFarling DA, Risser JM. A population-based study of acute stroke and TIA diagnosis. Neurology. 2004;62:895-900.


8. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e11-e12.

Measure Algorithm:

Measure Information Form CSTK-01
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Specifications Manual for Joint Commission National Quality Measures (v2019A)
Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19)

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