Thrombolytic Therapy

Last updated: May 17, 2016

CMS Measure ID: CMS91v5
Version: 5
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 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 than 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 the

  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 comfort measures documented on the day of or the day after arrival
  • Patients with intra-venous or intra-arterial Thrombolytic (t-PA) Therapy prior to arrival
  • Patients with documentation of a National Institutes for Health Stroke Scale (NIHSS) score of zero in the emergency department
  • Patients with Medical Reasons for not initiating IV thrombolytics documented by a physician/APN/PA or pharmacist on the day of or the day after arrival
  • Patients with any of the following results within 180 minutes of the
    1. time they were known to be at their baseline state of health; or
    2. time of symptom onset:
  • Prothrombin Time > 15 seconds
  • Platelet Count <100,000
  • INR<1.7
  • Partial Thromboplastin Time > 40 seconds
  • Systolic Blood Pressure > 185 mmHg
  • Diastolic Blood Pressure > 110 mmHg
  • Patient refusal
Measure Steward: The Joint Commission
Domain: Effective Clinical Care
Short Name: Stroke4
Next Version: Thrombolytic Therapy
Previous Version: Thrombolytic Therapy
Measure Score: Proportion
Improvement Notation:

Improvement is noted as an increase in 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.

Specifications

Release Notes

Header

  • Copyright updated.
  • eMeasure version number incremented.
  • Removed reference to observation patients from guidance header field, since value set does not include observation encounters.

Logic

  • Added '<= 120 minute(s) ends before start of 'Occurrence A of Encounter, Performed: Emergency Department Visit' to each 'Physical Exam, Performed: Baseline State' statement in the Numerator and Denominator Exceptions to clarify the logic in the left-hand side or right-hand side of a timing clause.
  • Added '<= 120 minute(s) starts before start of 'Occurrence A of Encounter, Performed: Emergency Department Visit' to each 'Physical Exam, Performed: Time of Symptom Onset' statement in the Numerator and Denominator Exceptions to clarify the logic in the left-hand side or right-hand side of a timing clause.
  • Added Denominator Exception for Comfort Measure Documented the day of or day after arrival. Modified the timing of 'Medication, Administered not done: Medical Reason' and 'Medication, Order not Done: Medical Reason' to the day of or day after arrival in order to align with chart-abstracted measure.
  • Changed data type of 'Result' or 'Finding' to 'Performed'.
  • Introduced function 'satisfies all' to specify that qualifying events must meet all conditions from a set of conditions or 'satisfies any' to specify that qualifying events must meet at least one condition from a set of conditions to streamline expression logic.
  • Introduced occurrencing on variables to enforce that the same instance of a clinical event is used throughout the measure when the logic within the variable does not limit the event to a single instance, e.g., FIRST or MOST RECENT.
  • Introduced variables $EncounterInpatientNonElective, $InterventionComfortMeasures, and $MedicalReasonForNotInitiatingIVThrombolytic to allow re-use of logical expressions and reduce redundancy/complexity.
  • Modified the the timing of the documentation of an NIHSS score = 0 to look for a FIRST NIHSS score when NIHSS=0 and is documented in the ED.
  • Removed Denominator Exception for NIHSS>22 based on recent clinical guidance.
  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • Replaced timing relationship 'ends before start of' with 'ends before or concurrent with start of' in logic criteria relating 'Encounter, Performed: Emergency Department Visit' and $EncounterInpatient, allowing for the Emergency Department Visit discharge to occur in the same minute as the inpatient admission.
  • The top level logical operator for the Numerator Exclusions, Denominator Exclusions, Denominator Exceptions, and Measure Population Exclusions defaults to 'OR'.

Value Sets

No changes

External Resources