Stroke Performance Measurement Implementation Guide, 2nd Edition by ebo15297

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									                          Stroke Performance Measurement Implementation Guide, 2nd Edition

Release Notes Version 1.1                                                                                  October 1, 2008


  Manual           Impacts               Rationale               Description of            Page        Implementation Date
  Section                                                          Changes
General Data Elements
Data           Discharge Status   Code change                 Delete Code 41            Section 5,   01/01/09
Dictionary     data element                                   “Expired in medical       Page 27,
                                                              facility, such as         28
                                                              hospital, SNF, ICF, or
                                                              freestanding hospice.
                                                              Usage note: For use on
                                                              Medicare and
                                                              CHAMPUS (TRICARE)
                                                              claims for hospice
                                                              care.”
                                                              Add Code 70 “
                                                              Discharged/transferred
                                                              to another Type of
                                                              Health Care Institution
                                                              not Defined Elsewhere
                                                              in this Code List (See
                                                              Code 05)
Comfort Measures Only
Data          Comfort Measures    Abstraction clarification   Suggested Data            Section 5,   01/01/09
Dictionary    Only                                            Sources:                  Page 22
              data element                                    Change “nurse
                                                              practitioner” to
                                                              “advanced practice
                                                              nurse”
Data           Comfort Measures   Abstraction clarification   Notes for Abstraction     Section 5,   01/01/09
Dictionary     Only                                           Add data abstraction      Page 22
               data element                                   guidelines for “comfort
                                                              measures only by end




                                                                    1
                                                                  of hospital day two (i.e.,
                                                                  If comfort measures
                                                                  only is documented by
                                                                  the end of hospital day
                                                                  two, select “Yes” for
                                                                  measures STK-1: DVT
                                                                  Prophylaxis and STK-5:
                                                                  Antithrombotic Therapy
                                                                  By End of Hospital Day
                                                                  Two. Documentation
                                                                  of comfort measures
                                                                  later than hospital day
                                                                  two = “No”.
Data           Comfort Measures       Abstraction clarification   Guidelines for               Section 5,    01/01/09
Dictionary     Only                                               Abstraction/Inclusion:       Page 23
               data element                                       Delete “V66.7
                                                                  encounter for palliative
                                                                  care”.
Admitted for Elective Carotid Endarterectomy
Algorithm        Admitted for         Name change                 Change “Admitted for         Section 4,    01/01/09
                 Elective Carotid                                 Elective Carotid             Pages 4-3
                 Endarterectomy                                   Endarterectomy” to           & 4-4
                 data element                                     “Admitted for Elective
                                                                  Carotid Intervention”
Data           Admitted for           Data definition revision    Change “Admitted for         Section 5,    01/01/09
Dictionary     Elective Carotid                                   Elective Carotid             Page 3
               Endarterectomy                                     Endarterectomy” to
               data element                                       “Admitted for Elective
                                                                  Carotid Intervention”
Measure        Patients admitted      Clarification of            Change “Patients             Section 4     01/01/09
Information    for elective carotid   populations excluded        admitted for elective        Pages 4-6,
               endarterectomy         from the denominator        carotid edartectomy” to      10, 14, 18,
               Excluded                                           “Patients admitted for       22, 26, 31,
               Populations List                                   elective carotid             34, 39, 43
                                                                  intervention” in list of
                                                                  excluded populations
                                                                  for all MIFs




                                                                        2
Stroke
Deep Vein Thrombosis (DVT) Prophylaxis
Data          Patient             Abstraction clarification       Notes for Abstraction       Section 5,    01/01/09
Dictionary    Ambulatory at End                                   Change “Patients            Page 52
              of Hospital Day                                     ambulating to and from
              Two                                                 the bathroom” to
              data element                                        “Patients ambulating to
                                                                  and from the bathroom
                                                                  throughout the day with
                                                                  or without assistance of
                                                                  another person or
                                                                  assistive device”.
                                                                  Change “Patient is only
                                                                  getting out of bed to the
                                                                  bedside commode (or
                                                                  up in chair)…” to
                                                                  “Patient is only
                                                                  transferred/getting out
                                                                  of bed to bedside
                                                                  commode (or up in
                                                                  chair/bed chair)…”
Glossary        Ambulatory          Clarification of definition   Change “Patient             Section 11,   01/01/09
                definition                                        walking without             Page 11-1
                                                                  assistance (no help
                                                                  form another person);”
                                                                  to “Patient walking
                                                                  without assistance (no
                                                                  help form another
                                                                  person) or walking
                                                                  throughout the day with
                                                                  the assistance of
                                                                  another person or
                                                                  assistive device; able
                                                                  to walk about, not
                                                                  bedridden or confined
                                                                  to bed.”
Data            DVT Prophylaxis     Abstraction clarification     Notes for Abstraction       Section 5,    01/01/09




                                                                        3
Dictionary      Initiated by End of                               Change “nurse                Page 29
                Hospital Day Two                                  practitioner” to
                data element                                      “advanced practice
                                                                  nurse”
Discharged on Antithrombotic Therapy
Measure        STK-2:              Clarification of               Delete Patients who          Section 4,   01/01/09
Information    Discharged on       populations excluded           expired “from a medical      Page 4-10
               Antithrombotic      from denominator               facility” from the list of
               Therapy                                            excluded populations.
                                                                  Retain “Patients who
                                                                  expired”.
                                                                  Change “Patients for
                                                                  whom discharge
                                                                  destination cannot be
                                                                  determined or missing”
                                                                  to “Patients for whom
                                                                  discharge destination
                                                                  cannot be determined
                                                                  or unknown”.
Data            Antithrombotic        Abstraction clarification   Notes for Abstraction        Section 5,   01/01/09
Dictionary      Therapy                                           Change “nurse                Page 11
                Prescribed at                                     practitioner” to
                Discharge                                         “advanced practice
                data element                                      nurse”
Data            Antithrombotic        Abstraction clarification   Guidelines for               Section 5,   01/01/09
Dictionary      Therapy                                           Abstraction/Exclusion:       Page 11
                Prescribed at                                     Add “Patients who are
                Discharge                                         discharged only on low
                data element                                      doses (5000 units subQ
                                                                  bid) of heparin or
                                                                  equivalent doses for
                                                                  DVT Prophylaxis using
                                                                  LMWH”
Patients with Atrial Fibrillation Receiving Anticoagulation Therapy
Measure           STK-3: Patients        Clarification of           Change “Patients with      Section 4,   01/01/09
Information       with Atrial            performance measure        Atrial Fibrillation        Page 4-13
                  Fibrillation           name                       Receiving




                                                                        4
              Receiving                                          Anticoagulation
              Anticoagulation                                    Therapy” to “Patients
              Therapy                                            with Atrial Fibrillation /
                                                                 Flutter Receiving
                                                                 Anticoagulation
                                                                 Therapy”
Algorithm     Atrial Fibrillation   Name change                  Change “Atrial               Section 4,   01/01/09
              data element                                       Fibrillation” data           Page 4-16
                                                                 element name to “Atrial
                                                                 Fibrillation/Flutter”
Measure       STK-3: Patients       Clarification of rationale   Change “The                  Section 4,   01/01/09
Information   with Atrial                                        administration of            Page 4-13
              Fibrillation                                       antithrombotic therapy”
              Receiving                                          to “The administration
              Anticoagulation                                    of anticoagulation
              Therapy                                            therapy”.
Measure       STK-3: Patients       Clarification of             Add “Patients for whom       Section 4,   01/01/09
Information   with Atrial           populations excluded         discharge destination        Page 4-14
              Fibrillation          from denominator             cannot be determined
              Receiving                                          or unknown” to list of
              Anticoagulation                                    excluded populations
              Therapy                                            Add “(home or facility)”
                                                                 to exclusion “Patients
                                                                 discharged to hospice”.
Data          Atrial Fibrillation   Name change                  Change “Atrial               Section 5,   01/01/09
Dictionary    data element                                       Fibrillation” data           Page 17
                                                                 element name to “Atrial
                                                                 Fibrillation/Flutter”
Data          Patient               Abstraction clarification    Notes for Abstraction        Section 5,   01/01/09
Dictionary    Discharged on                                      Change “nurse                Page 53
              Anticoagulation                                    practitioner” to
              Therapy                                            “advanced practice
              data element                                       nurse”
Data          Patient               Clarification of Allowable   Change “NC (No,              Section 5,   01/01/09
Dictionary    Discharged on         Values for NC path           documented reason for        Page 53
              Anticoagulation                                    not prescribing
              Therapy                                            antithrombotic therapy




                                                                       5
                data element                                    exists” to “NC (No,
                                                                anticoagulation therapy
                                                                was not prescribed at
                                                                discharge. A
                                                                documented reason
                                                                exists for not
                                                                prescribing this
                                                                therapy”.
Thrombolytic Therapy Administered
Data           IV Thrombolytic    Abstraction clarification     Notes for Abstraction      Section 5,   01/01/09
Dictionary     Therapy                                          Delete “or clearly         Page 47
               Administered                                     implied (e.g.,
               data element                                     contraindicated)” from
                                                                sentence 1, paragraph
                                                                2

Data            IV Thrombolytic     Abstraction clarification   Notes for Abstraction      Section 5,   01/01/09
Dictionary      Therapy                                         Change “nurse              Page 47
                Administered                                    practitioner” to
                data element                                    “advanced practice
                                                                nurse”
Antithrombotic Therapy by End of Hospital Day Two
Measure          STK-5:             Clarification of            Add “Patients receiving    Section 4,   01/01/09
Information      Antithrombotic     populations excluded        comfort measures only      Page 4-22
                 Therapy            from denominator            by end of hospital day
                 Administered by                                two”
                 End of Hospital                                Add “Patients admitted
                 Day Two                                        for the performance of
                                                                elective carotid
                                                                intervention” to list of
                                                                excluded populations.
Measure         STK-5:              Add exclusion to            Add “Patients who          Section 4,   01/01/09
Information     Antithrombotic      denominator population      received IV or IA          Page 4-22
                Therapy                                         thrombolytic therapy at
                Administered by                                 your hospital or another
                End of Hospital                                 hospital” as a new
                Day Two                                         exclusion




                                                                      6
Algorithm       STK-5:             Add decision point          Add “Patient received      Section 4,   01/01/09
                Antithrombotic                                 IV/IA thrombolytic         Page 4-24
                Therapy                                        therapy?”
                Administered by
                End of Hospital
                Day Two
Data            Patient Received   Add data definition         Add definition for data    Section 5,   01/01/09
Dictionary      IV/IA                                          element titled, “Patient   Page 54
                Thrombolytic                                   Received IV/IA
                Therapy                                        Thrombolytic Therapy”
                data element
Data            Antithrombotic     Abstraction clarification   Notes for Abstraction      Section 5,   01/01/09
Dictionary      Therapy                                        Change “nurse              Page 9
                Administered by                                practitioner” to
                End of Hospital                                “advanced practice
                Day Two                                        nurse”
                data element                                   Delete “thrombolytic
                                                               therapy (tPA)
                                                               administered within the
                                                               past 24 hours”
Data            Antithrombotic     Abstraction clarification   Guidelines for             Section 5,   01/01/09
Dictionary      Therapy                                        Abstraction/Exclusion:     Page 9
                Administered by                                Add “Patients who are
                End of Hospital                                prescribed only low
                Day Two                                        doses (5000 units subQ
                data element                                   bid) of heparin or
                                                               equivalent doses for
                                                               DVT Prophylaxis using
                                                               LMWH”
Discharged on Cholesterol Reducing Medication
Measure         STK-6:             Name revision               Change “STK-6:             Section 4,   01/01/09
Information     Cholesterol                                    Cholesterol Reducing       Pages 4-25
                Reducing                                       Therapy Prescribed At      to 4-28
                Therapy                                        Discharge” to “STK-6:
                Prescribed At                                  Discharged on Statin
                Discharge                                      Medication”.




                                                                     7
Algorithm      STK-6:              Algorithm revision          Change “STK-6:             Section 4,
               Cholesterol                                     Cholesterol Reducing       Page 4-29
               Reducing                                        Therapy Prescribed At
               Therapy                                         Discharge” to “STK-6:
               Prescribed At                                   Discharged on Statin
               Discharge                                       Medication”.
Algorithm      STK-6:              Add decision point          Add “Evidence of           Section 4,    01/01/09
               Discharged on                                   Atherosclerosis?”          Page 4-29
               Statin Medication
Data           Cholesterol         Data definition revision    Replace “Cholesterol       Section 5,    01/01/09
Dictionary     Reducing                                        ReducingTherapy            Page 63
               Therapy                                         Prescribed at
               Prescribed at                                   Discharged” with “Statin
               Discharge                                       Medication Prescribed
               data element                                    at Discharge”.
Appendices     Medication Table    Medication table revision   Add “Appendices Table      Section 13,   01/01/09
                                                               4 Statin Medications”.     Page App-
                                                                                          5
Data           LDL Measured        Add data definition         Add definition for data    Section 5,    01/01/09
Dictionary     data element                                    element “LDL               Page 50
                                                               Measured”
Data           Evidence of         Add data definition         Add definition for data    Section 5,    01/01/09
Dictionary     Atherosclerosis                                 element, “Evidence of      Page 43
               data element                                    Atherosclerosis”
Dysphagia Screening
Measure        STK-7:              Clarification of            Change “simple valid       Section 4,    01/01/09
Information    Dysphagia           performance measure         bedside testing            Page 4-30
               Screening           name                        protocol” to
                                                               “evidence-based
                                                               bedside testing protocol
                                                               approved by the
                                                               hospital”.
Data           Dysphagia           Abstraction clarification   Notes for Abstraction      Section 5,    01/01/09
Dictionary     Screen                                          Delete “All patients       Page 31
               data element                                    except those with a
                                                               known history of
                                                               dysphagia should have




                                                                     8
                                                             evidence of a
                                                             dysphagia screen prior
                                                             to any oral intake.”
Data            Dysphagia        Abstraction clarification   Notes for Abstraction      Section 5,   01/01/09
Dictionary      Screen                                       Delete “or clearly         Page 31
                data element                                 implied” from sentence
                                                             1, paragraph 2

Data            Dysphagia        Abstraction clarification   Notes for Abstraction      Section 5,   01/01/09
Dictionary      Screen                                       Change “nurse              Page 31
                data element                                 practitioner” to
                                                             “advanced practice
                                                             nurse”
Stroke Education
Measure          STK-8: Stroke   Clarification of            Change “given              Section 4,   01/01/09
Information      Education       performance measure         education or               Page 4-33
                                 name                        educational materials
                                                             during the hospital
                                                             stay…” to “given
                                                             education and/or
                                                             educational materials
                                                             during the hospital
                                                             stay.”
                                                             Change “medications
                                                             prescribed” to
                                                             “medications prescribed
                                                             at discharge”.
Measure         STK-8: Stroke    Clarification of            Add “Patients for whom     Section 4,   01/01/09
Information     Education        populations excluded        discharge destination      Page-34
                                 from denominator            cannot be determined
                                                             or unknown” to list of
                                                             excluded populations
                                                             Add “(home or facility)”
                                                             to exclusion “Patients
                                                             discharged to hospice”.
Measure         STK-8: Stroke    Algorithm clarification     Change “medications        Section 4,   01/01/09
Information     Education                                    prescribed” to             Page 4-36




                                                                   9
                                                                 “medications prescribed
                                                                 at discharge”.
Data           Education           Clarification of definition   Change “medication         Section 5,   01/01/09
Dictionary     Addresses                                         prescribed” to             Page 37
               Medication                                        “medication prescribed
               Prescribed                                        at discharge”.
               data element
Smoking Cessation / Advice / Counseling
Measure        STK-9: Smoking      Clarification of              Add “Patients for whom     Section 4,   01/01/09
Information    Cessation           populations excluded          discharge destination      Page 4-39
                                   from denominator              cannot be determined
                                                                 or unknown” to list of
                                                                 excluded populations
                                                                 Add “(home or facility)”
                                                                 to exclusion “Patients
                                                                 discharged to hospice”.
Assessed for Rehabilitation
Measure         STK-10:              Clarification of            Add “Patients for whom     Section 4,   01/01/09
Information     Assessed for         populations excluded        discharge destination      Page 4-43
                Rehabilitation       from denominator            cannot be determined
                                                                 or unknown” to list of
                                                                 excluded populations
                                                                 Add “(home or facility)”
                                                                 to exclusion “Patients
                                                                 discharged to hospice”.
Glossary
Definitions                          New definitions added       Add definitions for the    Section 11   01/01/09
                                                                 following terms:
                                                                 angioplasty,
                                                                 atherosclerosis,
                                                                 elective carotid
                                                                 intervention, statin,
                                                                 stent




                                                                      10
11
                              Stroke Performance Measurement Implementation Guide, 2nd Edition

Release Notes Version 1.0                                                                                          December 10, 2007


  Manual              Impacts                   Rationale              Description of             Page         Implementation Date
  Section                                                                Changes
General Data Elements
Admission Source
Data           Alphabetical Data         Changes made by the        Replace data element,      Section 5,    01/01/2008
Dictionary     Element List              National Uniform Billing   Admission Source, with     Page 1
                                         Committee (NUBC)           data element, Point of
                                                                    Origin for Admission or
                                                                    Visit
Data             Admission Source        Changes made by the        Delete Admission           Section 5,    01/01/2008
Dictionary       data element            NUBC                       Source                     Pages 3 &
                                                                                               4
Point of Origin for Admission or Visit
Data              Point of Origin for    Changes made by the        Add Point of Origin for    Section 5,    01/01/2008
Dictionary        Admission or Visit     NUBC                       Admission or Visit         Pages 53 &
                  data element                                                                 54
Measure           All Measures           Changes made by the        Delete Admission           Section 4,    01/01/08
Information                              NUBC                       Source from list of        Pages 4-6;
                                                                    General Data Elements      4-10; 4-14;
                                                                    Add Point of Origin for    4-18; 4-22;
                                                                    Admission or Visit to      4-30; 4-33;
                                                                    list of General Data       4-38; 4-42
                                                                    Elements
Discharge Status
Data            Discharge Status         Changes made by the        Add “usage Note” to        Section 5,    01/01/08
Dictionary      data element             NUBC                       Value “05”: Cancer         Page 29
                                                                    hospitals excluded from
                                                                    Medicare PPS and
                                                                    children’s hospitals are
                                                                    examples of such other
                                                                    types of health care
                                                               institutions.
Stroke
Discharged on Cholesterol Reducing Medication
Data           Cholesterol         Abstraction clarification   Add                           Section 5,   01/01/08
Dictionary     Reducing Therapy                                Notes for Abstraction         Page 22
               Prescribed At                                   -If documentation by a
               Discharge                                       physician, nurse
               data element                                    practitioner, or
                                                               physician assistant is
                                                               present in the chart that
                                                               indicates that the
                                                               stroke was not of an
                                                               atherosclerotic origin or
                                                               that the patient does
                                                               not meet NCEP ATPIII
                                                               criteria for lipid lowering
                                                               therapy, select “NC”.
Measure         STK-6:               Rationale clarification   Change “Based on              Section 4,   01/01/08
Information     Cholesterol                                    these guidelines, all         Page 4-25
                Reducing Therapy                               patients with ischemic
                Prescribed At                                  stroke should have lipid
                Discharge                                      profile measurement
                                                               performed within 48
                                                               hours of admission
                                                               unless outpatient
                                                               results are available
                                                               from within the past 30
                                                               days. Treatment for
                                                               secondary prevention
                                                               should be initiated in
                                                               the presence of LDL>
                                                               100 mg/dL, or
                                                               continued for patients
                                                               who were previously on
                                                               lipid-lowering therapy
                                                               and have an LDL< 100
                                                               mg/dL” to “Based on
                                                              these guidelines, all
                                                              patients with ischemic
                                                              stroke should have lipid
                                                              profile measurement
                                                              performed within 48
                                                              hours of admission
                                                              unless outpatient
                                                              results are available
                                                              from within the past 30
                                                              days. Treatment for
                                                              secondary prevention
                                                              should be initiated in
                                                              patients who meet
                                                              NCEP ATP III criteria in
                                                              the presence of LDL>
                                                              100 mg/dL, or
                                                              continued for patients
                                                              who were previously on
                                                              lipid-lowering therapy
                                                              and have an LDL< 100
                                                              mg/dL.”


Deep Vein Thrombosis (DVT) Prophylaxis
Data          Patient             Abstraction clarification   Change Notes for           Section 5,   01/01/08
Dictionary    Ambulatory at End                               Abstraction, “To           Page 51
              of Hospital Day                                 compute end of hospital
              Two                                             day two, count the day
              data element                                    of admission as
                                                              hospital day one.” to
                                                              “To compute end of
                                                              hospital day two, count
                                                              the arrival date as
                                                              hospital day one.”
Thrombolytic Therapy Administered
Measure        STK-4:             Flowchart clarification     Add “ND” (= Time not       Section 4,   01/01/08
Information    Thrombolytic                                   documented or              Page 4-20
                Therapy                                         unknown at the time
                Administered                                    treatment decision was
                                                                made) to string
                                                                “> 2hrs → Stop. Not in
                                                                population”.
Assessed for Rehabilitation
Measure        STK-10: Assessed      Flowchart clarification    Add “07” to string of       Section 4,   01/01/08
Information    for Rehabilitation                               “Discharge Status”          Page 4-43
                                                                codes not included in
                                                                population. Delete “07”
                                                                from string of
                                                                “Discharge Status”
                                                                codes included in
                                                                measure population.
                                                                Add “43” to string of
                                                                “Discharge Status”
                                                                codes included in
                                                                measure population.
Antithrombotic Therapy by End of Hospital Day Two
Data             Antithrombotic     Abstraction clarification   Add                         Section 5,   01/01/08
Dictionary       Therapy                                        Notes for Abstraction       Page 10
                 Administered by                                “Thrombolytic therapy
                 End of Hospital                                administered within
                 Day Two                                        past 24 hours” to list of
                 data element                                   conditions or factors
                                                                making the
                                                                administration of
                                                                antithrombotic therapy
                                                                inadvisable,
                                                                inappropriate and/or
                                                                undesirable

								
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