Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
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Release Notes:
Data Element
Version 2020B

Name:Education Addresses Activation of Emergency Medical System
Collected For: STK-8
Definition:Documentation that the patient/caregiver received educational materials that address the need for activation of the emergency medical system (EMS) if signs or symptoms of stroke occur. Immediate activation of the emergency medical system by calling 911 or another EMS number improves hospital arrival time and the likelihood of thrombolytic administration.
Question:Did the WRITTEN instructions or other documentation of educational material given to the patient/caregiver address activation of the emergency medical system (EMS) if signs or symptoms of stroke occur?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes)     WRITTEN instructions/educational material given to patient/caregiver address activation of the emergency medical system (EMS) if signs or symptoms of stroke occur.

N (No)     WRITTEN instructions/educational material given to patient/caregiver do not address activation of the emergency medical system (EMS) if signs or symptoms of stroke occur, OR unable to determine from medical record documentation.

Notes for Abstraction:
  • Educational material must address activation of the emergency medical system (EMS) if signs or symptoms of stroke or transient ischemic attack (TIA) occur.
    Example:
    “Call 911 immediately if you experience signs or symptoms of stroke, such as sudden numbness or weakness of an extremity.”
  • If the medical record does not contain documentation of education regarding stroke and EMS activation, select “No.”
    Examples:
    • “Stroke binder given to patient’s family.”
    • “Aneurysm education completed.”
  • If documentation reflects educational material regarding EMS activation was given to the patient/caregiver, select “Yes”, even if a copy of the material is not present in the medical record.
  • Documentation must clearly convey that the patient/caregiver was given a copy of the material to take home. When the material is present in the medical record and there is no documentation which clearly suggests that a copy was given, the inference should be made that it was given IF the patient's name or the medical record number appears on the material AND hospital staff or the patient/caregiver has signed the material. An electronic staff signature is acceptable. This applies to educational materials in the form of printed, electronic, or digital patient-oriented materials. Providing a link to electronic materials is not sufficient.
  • Use only documentation provided in the medical record itself. Do not review and use outside materials in abstraction. Do not make assumptions about what content may be covered in material documented as given to the patient/caregiver.
  • Written instructions given anytime during the hospital stay are acceptable.
  • If there is documentation that instructions were given or sent to the patient/caregiver after discharge, select “No.”
  • If the patient refused written instructions/material which addressed activation of the emergency medical system (EMS) if signs or symptoms of stroke occur, select “Yes.”
  • If documentation indicates that written instructions/material on activation of the emergency medical system (EMS) were not given because the patient is cognitively impaired (e.g., comatose, obtunded, confused, short-term memory loss) and has no caregiver available, select “Yes.”
  • The caregiver is defined as the patient’s family or any other person (e.g.,home health, VNA provider, prison official or other law enforcement personnel) who will be responsible for care of the patient after discharge.
Suggested Data Sources:
  • Nursing notes
  • Progress notes
  • Discharge summary
  • After Visit Summary (AVS)
  • Discharge instruction sheet
  • Education Record
  • Home health referral form
  • Nursing discharge notes
  • Teaching sheet

Excluded Data Sources:
  • Any documentation dated/timed after discharge, except discharge summary
  • Core measure forms
Additional Notes:

Guidelines for Abstraction:
Inclusion Exclusion
Emergency Medical System
  • EMS
  • 911

Warning Signs and Symptoms of Stroke
  • F.A.S.T. (Face, Arms, Speech, Time)
  • Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
  • Sudden confusion, trouble speaking or understanding
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of balance or coordination
  • Sudden severe headache with no known cause

Unchecked checkbox next to instruction (e.g., blank checkbox on discharge instruction sheet next to “Activation of the Emergency Medical System”).

Education Addresses Activation of Emergency Medical System
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Specifications Manual for Joint Commission National Quality Measures (v2020B)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

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