Thrombolytic Therapy

Last updated: May 4, 2017

CMS Measure ID: CMS91v4
Version: 4
NQF Number: 0437
Measure Description:

Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours of time last known well.

Initial Patient Population:

Patients age 18 and older discharged from inpatient care (non-elective admissions) with a principal diagnosis of ischemic or hemorrhagic stroke and a length of stay less or equal to 120 days.

Denominator Statement:

Ischemic stroke patients admitted through the Emergency Department whose time of arrival is within 2 hours (less than or equal to 120 minutes) of

  1. time they were known to be at their baseline state of health; or
  2. time of symptom onset if time last known at baseline state is not known.
Denominator Exclusions:

None

Numerator Statement:

Acute ischemic stroke patients for whom IV thrombolytic therapy was initiated at this hospital within 3 hours (less than or equal to 180 minutes) of when it was witnessed or reported that the patient was last known to be without the signs and symptoms of the current stroke or at his or her baseline state of health.

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

Patients with a documented Reason For Not Initiating IV Thrombolytic.

Measure Steward: The Joint Commission
Domain: Effective Clinical Care
Short Name: Stroke4
Next Version: Thrombolytic Therapy
Measure Score: Proportion
Score Type: Process
Improvement Notation:

An increase in the rate

Guidance:

The unit of measurement for this measure is an inpatient episode of care. Each distinct hospitalization should be reported, regardless of whether the same patient is admitted for inpatient care more than once during the measurement period. In addition, the eMeasure logic intends to represent events within or surrounding a single occurrence of an inpatient hospitalization.

The baseline state value set and its associated effectiveTime intend to capture the date and time prior to hospital arrival at which it was witnessed or reported that the patient was last known to be without the signs and symptoms of the current stroke or at his or her baseline state of health. The time of symptom onset value set and its associated effectiveTime is intended to capture the date and time at which symptoms started if symptom onset was witnessed. Since none of the value sets make any specific reference to stroke, their use is only meaningful in the context of stroke-specific documentation, such as a stroke assessment form or template.

The Non-elective Inpatient Encounter value set intends to capture all non-scheduled hospitalizations. This value set is a subset of the Inpatient encounter value set, excluding concepts that specifically refer to elective hospital admissions. Non-elective admissions include emergency, urgent and unplanned admissions, including patients admitted for observation.

Specifications

External Resources