Specifications Manual for Joint Commission National Quality Measures (v2020A)
Posted: August 1, 2019
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

Home » Comprehensive Stroke (CSTK) » CSTK-12

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Measure Information Form
Version 2020A

Measure Information Form

Measure Set: Comprehensive Stroke (CSTK)

Set Measure ID: CSTK-12

Performance Measure Name: Timeliness of Reperfusion: Skin Puncture to TICI 2B or Higher

Description: Ischemic stroke patients with a large vessel cerebral occlusion (i.e., internal carotid artery (ICA) or ICA terminus (T-lesion; T-occlusion), middle cerebral artery (MCA) M1 or M2, basilar artery) who receive mechanical endovascular reperfusion (MER) therapy and achieve TICI 2B or higher less than (<) or equal to 60 minutes from the time of skin puncture.

Rationale: The Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade is used to measure cerebral reperfusion. Results with this scoring system range between zero and three: 0 (no perfusion); 1 (perfusion past the initial occlusion, but no distal branch filling); 2 (perfusion with incomplete or slow distal branch filling); and, 3 (full perfusion with filling of all distal branches). Reperfusion past the target arterial occlusion and into the distal arterial bed and terminal branches, in conjunction with recanalization of the target arterial occlusion, demonstrates flow restoration or revascularization.

Endovascular therapy (EVT) is now the standard of care for treatment of acute ischemic stroke due to large-vessel occlusion (LVO). In 2015, the American Heart Association/American Stroke Association published a focused update to the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke regarding endovascular treatment (Powers WJ, et. al., 2015). Endovascular therapy with a stent retriever is recommended for eligible patients. The use of mechanical thrombectomy devices other than stent retrievers as first-line devices for mechanical thrombectomy may be reasonable in some circumstances, but stent retrievers remain the first choice (Powers WJ, et. al., 2018).

To ensure benefit, reperfusion to TICI 2B/3 should be achieved as early as possible and within 6 hours of stroke onset. The DAWN Clinical Trial Investigators (Nogueira RG, et. al., 2018) reported the benefits of mechanical thrombectomy in the extended window up to 24 hours of last known well for select patients meeting certain criteria. As with IV alteplase (t-PA), reduced time from symptom onset to reperfusion with EVT is highly associated with better clinical outcomes. Recent recommendations from the Society of Vascular and Interventional Neurology (SVIN) offer procedural metrics which include time from hospital arrival to groin puncture less than 90 minutes, and time from groin puncture to TICI 2B or better or conclusion of procedure less than 60 minutes (English JD, et. al., 2016).

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients who achieve TICI 2B or higher for the primary vessel occlusion less than (<) or equal to 60 minutes from the time of skin puncture
Included Populations: As above

Excluded Populations: None

Data Elements:

Denominator Statement: Ischemic stroke patients treated with mechanical endovascular reperfusion therapy for a large vessel occlusion (LVO)
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, AND
  • 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) AND
  • Patients with documented Failed Attempt at Thrombectomy (ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 8.1c for ICD-10 codes)

Excluded Populations:
  • Patients less than 18 years of age
  • Patients who have a Length of Stay > 120 days
  • Patients admitted for Elective Carotid Intervention
  • Patients who have a primary cerebral occlusion that is not a large vessel occlusion (LVO)

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, Brott TG, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Kwiatkowski T, Lyden PD, Marler JR, Torner J, et. al. Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke. Circulation. 1996;94:1167-1174.

2.  Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et. al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. NEJM. 2018;378(8): 708-718.

3.  Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004.

4.  Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, et al. 2007 focused update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;51:210-—47.

5.  Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et. al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. NEJM. 2015 Mar;372(11): 1009-17.

6.  Demchuk AM, Goyal M, Monon BK, Eesa M, Ryckborst KJ, Kamal N, et. al. Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times (ESCAPE) trial: methodology. Int J Stroke. 2015 Apr;10(3): 429-38.

7.  English JD, Yavagal DR, Gupta R, Janardhan V, Zaidat OO, Xavier AR, Nogueira RG, Kirmani JF, Jovin TG. Mechanical thrombectomy-ready comprehensive stroke center requirements and endovascular stroke systems of care: recommendations from the endovascular stroke standards committee of the Society of Vascular and interventional Neurology (SVIN). Intervent Neurol. 2015;4:138-50.

8.  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.

9.  Khatari P, Abruzzo T, Yeatts SD, Nichols C, Broderick JP, Tomsick TA; IMS I and II Investigators. Good clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology. 2009 Sep 29;73(13):1066-72.

10.  Kole M, Amin B, Marin H, Russman A, Sanders W. Intracranial angioplasty and stent placement for direct cerebral revascularization o nonacute intracranial occlusions and near occlusions. Applications/LocalApps. NeuroSurg Focus. 2009; 26(3): E3.

11.  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.

12.  Menon BK, Saver JL, Prabhakaran S, Reeves M, Liang L, Olson DWM, Peterson ED, Hernandez AF, Fonarow GC, Schwamm LH, Smith EE. Risk score for intracranial hemorrhage in patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator. Stroke. 2012;43: 1-9.

13.  Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et. al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. NEJM. 2018;378(1): 11-21.

14.  Powers WJ, Derdeyn CP, Biller J, Coffey CS, Jauch EC, Johnston KC, Johnston SC, Khalessi AA, Kidwell CS, Meschia JF, Ovbiagele B, Yavagal DR, on behalf of the American Heart Association Stroke Council. 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46; 3021-3035.

15.  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:e26-e30.

16.  Pride GL, Fraser JF, Gupta R, Alberts MJ, Rutledge JN, Fowler R, et. al. Prehospital care delivery and triage of stroke with emergent large vessel occlusion (LVO): report of the Standards and Guidelines Committee of the Society of Neurointerventional Surgery (SNIS). Applications/LocalApps. NeuroIntervent Surg. 2016;0:1-11.

17.  Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke.

18.  Sacks D, Black CM, Cognard C, Connors III JJ, Frei D, Gupta R, Jovin TG, Kluck B, Meyers PM, Murphy KJ, Ramee S, Rϋfenacht DA, Stallmeyer MJB, Vorwerk D. Multisociety consensus quality improvement guidelines for intraarterial catheter-directed treatment of acute ischemic stroke from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology. J Vasc Interv Radiol. 2013;24:151-163.

19.  Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. NEJM. 2015 Apr: 1-11.

20.  Sharma VK, Teoh HL, Wong LYH, Su J, Ong BKC, and Chan BLP. Recanalization therapies in acute ischemic stroke: pharmacological agents, devices, and combinations. Stroke Research and Treatment. 2010.

21.  Sims JR, Gharai R, Schaefer PW, Vangel M, Rosenthal ES, Lev MH, Schwamm LH. ABC/2 for rapid clinical estimate of infarct, perfusion, and mismatch volumes. Neurology. 2009;72:2104-2110.

22.  Tomsick T, Broderick J, Carrosella J, Khatari P, Hill M, Palesch Y, Khoury J; Interventional Management of Stroke II Investigators. Revascularizaton results in the Interventional Management of Stroke II Trial. American Journal of Neuroradiology. 2008 Mar; 29(3): 582-587.

23.  Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et. al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014 May;694): 260-4.

Measure Algorithm:

Measure Information Form CSTK-12
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Specifications Manual for Joint Commission National Quality Measures (v2020A)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

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