Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020

Release Notes:
Measure Information Form
Version 2020B

Measure Information Form

Measure Set: Acute Stroke Ready Outpatient (ASR-OP)

Set Measure ID: ASR-OP-2

Set Measure ID Performance Measure Name
ASR-OP-2a viewtopic Door to Transfer to Another Hospital - Overall Rate
ASR-OP-2b viewtopic Door to Transfer to Another Hospital - Hemorrhagic Stroke
ASR-OP-2c viewtopic Door to Transfer to Another Hospital - Ischemic Stroke; Drip and Ship
ASR-OP-2d viewtopic Door to Transfer to Another Hospital - Ischemic Stroke; No IV Alteplase Prior to Transfer

Performance Measure Name: Door to Transfer to Another Hospital

Description: Median time from hospital arrival in the emergency department to transfer of a hemorrhagic stroke patient, an ischemic stroke patient (drip and ship), or an ischemic stroke patient (no IV alteplase given prior to transfer) to another hospital

Rationale: For the past ten years, the organization of acute stroke care in the United States has moved in the direction of stroke centers; however, many patients with an acute stroke live in areas without ready access to a Primary (PSC) or Comprehensive Stroke Center (CSC). A third designation of stroke center, the Acute Stroke Ready Hospital (ASRH), has emerged for hospitals that can provide timely, evidence-based care, i.e., initial diagnostic services, initial stroke diagnosis, stabilization, emergent care and therapies, to patients with an acute stroke who are seen in their emergency department.

Most patients with an acute stroke seen initially at an ASRH will require emergent transfer to a PSC or CSC. The Brain Attack Coalition recommends that such transfers occur within 2 hours of the patient presenting to the ASRH (Alberts, 2013). Additionally, written transfer agreements between the ASRH and at least one PSC or CSC and a transportation vendor with both ground and air ambulance transfer options are recommended. One in four patients are transferred while receiving intravenous (IV) alteplase (Sheth, 2015); others transferred after initiation of coagulopathy reversal treatment. Reducing the time stroke patients remain in the emergency department (ED) can improve access to a higher-level of stroke care and advanced intra-arterial or endovascular treatments, and increase quality of care. A door to needle time goal within 60 minutes should be established for acute ischemic stroke patients treated with IV alteplase. Door to needle times within 45 minutes may be reasonable for some patients (Powers, 2018). For those stroke patients who are not transferred to a PSC or CSC, inpatient admission within 3 hours, preferably to a formal stroke unit, is recommended (Jauch, 2013).

Type Of Measure: Process

Improvement Noted As: Decrease in the median value

Continuous Variable Statement:

ASR-OP-2b Time (in minutes) from ED arrival to transfer of a hemorrhagic stroke patient to another hospital

ASR-OP-2c Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (drip and ship) to another hospital

ASR-OP-2d Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (no IV alteplase prior to transfer) to another hospital

Included Populations:
  • Patients with an ICD-10-CM Principal Diagnosis Code for ischemic or hemorrhagic stroke as defined in Appendix A, Table 8.1 or Table 8.2
AND
  • Patients who are transferred to another hospital
AND
  • An E/M Code for emergency department encounter as defined in Appendix A, Table 1.0

Excluded Populations:
  • Patients less than 18 years of age
  • Patients with Comfort Measures Only documented on day of or day after arrival
  • Patients who expired in the emergency department
  • Discharges to dispositions other than an acute care facility

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest. This approach provides opportunities for improvement at the point of care/service. However, complete documentation includes the principal or other ICD-10 diagnosis and procedure codes, which require retrospective data entry.

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: No.

Data Reported As: Aggregate measure of central tendency .

Selected References:
  • Alberts MJ, Wechsler LR, Jensen MEL, Lachtaw RE, Crocco TJ, George MG, Baranski J, Bass RR, et al. “Formation and Function of Acute Stroke-Ready Hospitals Within a Stroke System of Care Recommendations From the Brain Attack Coalition” [In Eng]. Stroke (Nov 12 2013).
  • Albright KC, Branas CC, Meyer BC, Matherne-Meyer DE, Zivin JA, Lyden PD, Carr BG. “Acute Cerebrovascular Care in Emergency Stroke Systems.” [In Eng]. Arch Neurol (Oct 2010).
  • American Heart Association. Acute Stroke Ready Hospital, 2015.
  • Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, 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." [In Eng]. Stroke (Jan 31 2013).
  • Lyerly MJ, Albright KC, Boehme AK, Shahripour RB, Donnelly JP, Houston JT, Rawal PV, Kapoor N, Alvi M, Sisson A, Alexandrov AW, Alexandrov AV. “Patient Selection for Drip and Ship Thrombolysis in Acute Ischemic Stroke”. [In Eng]. South Med J (Jul 2015).
  • 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:e8, e10.
  • Sheth KN, Smith EE, Grau-Sepulveda MV, Kleindorfer D, Fonarow GC, Schwamm LH. "Drip and Ship Thrombolytic Therapy for Acute Ischemic Stroke: Use, Temporal Trends, and Outcomes.” [In Eng]. Stoke (Mar 2015).

Measure Algorithm:

Measure Information Form ASR-OP-2
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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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