Measure Information Form

Measure Set: Stroke Outpatient (STK-OP)

Set Measure ID: STK-OP-1

Set Measure ID	Performance Measure Name
STK-OP-1a	Overall Rate (Not Reported)
STK-OP-1b	Hemorrhagic Stroke
STK-OP-1c	Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) RETIRED 7/1/2021
STK-OP-1d	Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible
STK-OP-1e	Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible
STK-OP-1f	Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO
STK-OP-1g	Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible
STK-OP-1h	Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible
STK-OP-1i	Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO

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 or an ischemic stroke patient to another hospital.

Rationale: Hemorrhagic stroke is a life-threatening condition caused by a rupture in a weakened blood vessel in the brain. Surgical intervention to repair a ruptured aneurysm may be indicated and necessitate urgent transfer of the patient, if the hospital is unable to provide advanced neurological treatments and services.

The benefits of both IV altelplase and mechanical thrombectomy for the treatment of acute ischemic stroke are time dependent. The earlier the treatment within the time window, the greater the benefit to patients. Initiation of IV alteplase at a primary stroke center (PSC) and rapid transport to an advanced center capable of performing endovascular treatment may lead to faster and more complete reperfusion for certain patients eligible for these treatments (Powers, 2018).

In 2013, The Brain Attack Coalition recommended that stroke transfers occur within 2 hours of patient arrival at the referring stroke center (Alberts, 2013). Since that time, faster door-in-door-out (DIDO) times have been reported for specific groups of stroke patients. For hospitals without an on-site mechanical thrombectomy (MT) service, shorter door-in-door-out (DIDO) times should be the goal. Choi and colleagues recently reported a median DIDO time of 86 minutes (IQR, 65–111) for acute ischemic stroke patients transferred out for potential MT. During working hours (0800–1700 hours), a median DIDO time of 59 minutes (IQR, 51–80) was achieved (Choi, 2019). Prolonged transfer times may result in worse outcomes for MT-eligible patients with evolving large vessel occlusion (ELVO) who are without successful reperfusion. Higher NIHSS scores have been noted at discharge and 90 days (McTaggert, 2018).

Reducing the time stroke patients remain in the emergency department (ED) can improve access to a higher-level of stroke care, surgical intervention, or advanced intra-arterial endovascular treatments, and increase quality of care. For those stroke patients who are not transferred to a TSC 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:
STK-OP-1b Time (in minutes) from ED arrival to transfer of a hemorrhagic stroke patient to another hospital

STK-OP-1d Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (no IV alteplase given prior to transfer, LVO and MER eligible) to another hospital

STK-OP-1e Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (no IV alteplase given prior to transfer, LVO and NOT MER eligible) to another hospital

STK-OP-1f Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (no IV alteplase given prior to transfer, no LVO) to another hospital

STK-OP-1g Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (IV alteplase prior to transfer (drip and ship), LVO and MER eligible) to another hospital

STK-OP-1h Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (IV alteplase prior to transfer (drip and ship), LVO and NOT MER eligible) to another hospital

STK-OP-1i Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (IV alteplase prior to transfer (drip and ship), no LVO) 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:

Arrival Time

Birthdate

Comfort Measures Only

Discharge Code

E/M Code

ED Departure Date

ED Departure Time

ICD-10-CM Principal Diagnosis Code

IV Alteplase Initiation

MER Eligibility

Outpatient Encounter Date

Suspected Large Vessel Occlusion (LVO)

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.
Choi PMC, Tsoi AH, Pope AL, Leung S, Frost T, Loh PS, Chandra RV, Ma T, Parsons M, Mitchell P, Dewey HM. “Door-in-Door-Out Time of 60 Minutes for Stroke With Emergent Large Vessel Occlusion at a Primary Stroke Center.” [In Eng]. Stroke (Aug 29 2019).
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).
McTaggert RA, Moldovan K, Oliver LA, Dibiasio EL, Baird GL, Hemendinger ML, Haas RA, Goyal M, Wang TY, Jayaraman MV. “Door-in-Door-Out Time at Primary Stroke Centers May Predict Outcome for Emergent Large Vessel Occlusion Patients.” [In Eng]. Stroke (Nov 8 2018).
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:

Specifications Manual for Joint Commission National Quality Measures (v2023A1)
Discharges 01-01-23 (1Q23) through 06-30-23 (2Q23)

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