Thrombolytic Therapy

Last updated: January 31, 2017

CMS Measure ID: CMS91v6
Version: 6
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 the very first 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/mm3
    • INR>1.7
    • Partial Thromboplastin Time > 40 seconds
    • Systolic Blood Pressure > 185 mmHg
    • Diastolic Blood Pressure > 110 mmHg
    • Patient refusal
  • Patients with documentation of the following Reasons for Extending the Initiation of IV Thrombolytic within 270 minutes of the 1) time they were known to be at their baseline state of health; or 2) time of symptom onset:
    • Patient refusal
    • Antihypertensive Medication administered, and either Systolic Blood Pressure > 185 mmHg OR Diastolic Blood Pressure > 110 mmHg
    • AND received IV administration of IV Thrombolytic (t-PA) Therapy
Measure Steward: The Joint Commission
Domain: Effective Clinical Care
Short Name: Stroke4
Previous Version: Thrombolytic Therapy
Improvement Notation:

Improvement is noted as an increase in rate

Guidance:

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.

In the denominator, the measure looks to identify the relationship between the Baseline State or Symptom onset and the encounter. In the numerator, the data elements are used to identify the relationship between the administration of t-PA and the time of either Baseline State or Symptom Onset. In both cases, the eCQM uses Baseline State and Time of Symptom Onset interchangeably.

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

  • Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • Added unit of measurement to platelet count because it was missing.

    Section: Denominator Exceptions

    Source: JIRA (CQM-1538)

  • Updated criteria in the Denominator Exceptions representing reasons for extending the initiation of IV thrombolytic to align better with the chart-abstracted measure.

    Section: Denominator Exceptions

    Source: Chart Abstracted Measures

  • Updated criteria in the Denominator Exceptions representing reasons for extending the initiation of IV thrombolytic to align better with the chart-abstracted measure.

    Section: Denominator Exceptions

    Source: JIRA (CQM-1332)

  • Updated Denominator Exceptions header to clarify intent of measure logic.

    Section: Denominator Exceptions

    Source: JIRA (CQM-1658)

  • Updated the Denominator Exceptions header statement to better align with measure logic and intent.

    Section: Denominator Exceptions

    Source: JIRA (CQM-1659)

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Measure Lead

  • Added additional guidance to clarify the intent of the Baseline State and Time of Symptom Onset data elements.

    Section: Guidance

    Source: JIRA (CQM-1637)

  • Removed unit of measurement language from Guidance. HQMF now has a header field, 'measure item count', where the unit of measurement can be identified in a computable fashion.

    Section: Guidance

    Source: Measure Lead

Logic

  • Replaced 'Diagnosis, Active: XXX (ordinality: Principal)' datatype with 'Encounter, Performed: XXX (principal diagnosis: XXX)' datatype to conform with QDM 4.2 changes and provide more accurate logic.

    Section: Denominator

    Source: QDM Standards

  • Added unit of measurement to platelet count because it was missing.

    Section: Denominator Exceptions

    Source: JIRA (CQM-1538)

  • Modified ‘OR: First: 'Occurrence A of Risk Category Assessment: National Institute of Health Stroke Scale (result = 0 )' starts during 'Occurrence A of Encounter, Performed: Emergency Department Visit'’ in the Denominator Exception logic. Changed logic to read:

    —OR:

    —AND: First: Occurrence A of 'Risk Category Assessment: National Institute of Health Stroke Scale' starts during 'Occurrence A of Encounter, Performed: Emergency Department Visit'

    —AND: Occurrence A of Risk Category Assessment: National Institute of Health Stoke Scale (result=0)

    This change is to better align with the intent of the measure.

    Section: Denominator Exceptions

    Source: Measure Lead

  • Replace Procedure, Performed: Intravenous Thrombolytic (t-PA) Therapy OID: 2.16.840.1.113762.1.4.1045.15 with Procedure, Performed: Intravenous or Intra-arterial Thrombolytic (t-PA) Therapy OID: 2.16.840.1.113762.1.4.1045.21.

    Section: Denominator Exceptions

    Source: Measure Lead

  • Updated criteria in the Denominator Exceptions representing reasons for extending the initiation of IV thrombolytic to align better with the chart-abstracted measure.

    Section: Denominator Exceptions

    Source: Chart Abstracted Measures

  • Updated criteria in the Denominator Exceptions representing reasons for extending the initiation of IV thrombolytic to align better with the chart-abstracted measure.

    Section: Denominator Exceptions

    Source: JIRA (CQM-1332)

  • Introduced the operator 'Intersection of' to condense logic and reduce complexity.

    Section: Initial Population

    Source: Measure Lead

  • Replaced 'Diagnosis, Active: XXX (ordinality: Principal)' datatype with 'Encounter, Performed: XXX (principal diagnosis: XXX)' datatype to conform with QDM 4.2 changes and provide more accurate logic.

    Section: Initial Population

    Source: QDM Standards

  • Added new attribute 'principal diagnosis' to 'Encounter, performed' datatype to conform to QDM 4.2 changes and provide more accurate logic. Removed QDM data element Attribute: 'Ordinality: Principal' using 'Principal SNOMEDCT Value Set (2.16.840.1.113883.3.1.7.1.14.)’ to conform to QDM 4.2. changes and provide more accurate logic.

    Section: QDM Data Elements

    Source: QDM Standards

  • Replace Procedure, Performed: Intravenous Thrombolytic (t-PA) Therapy OID: 2.16.840.1.113762.1.4.1045.15 with Procedure, Performed: Intravenous or Intra-arterial Thrombolytic (t-PA) Therapy OID: 2.16.840.1.113762.1.4.1045.21.

    Section: QDM Data Elements

    Source: Measure Lead

  • Value set IV AntiHypertensives (2.16.840.1.113762.1.4.1110.10): Added IV AntiHypertensives.

    Section: QDM Data Elements

    Source: None

Value Set

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Added 3 SNOMEDCT codes (230701008, 307363008, 426107000) and deleted 5 SNOMEDCT codes (233964008, 288723005, 300920004, 64586002, 71444005). Deleted 18 ICD10CM codes.

    Section: None

    Source: None

  • Value set IV AntiHypertensives (2.16.840.1.113762.1.4.1110.10): Added IV AntiHypertensives.

    Section: None

    Source: None

  • Value set Medical Reason (2.16.840.1.113883.3.117.1.7.1.473): Deleted 1 SNOMEDCT code (161590003).

    Section: None

    Source: None

  • Value set Partial Thromboplastin Time (2.16.840.1.113762.1.4.1045.25): Added 11 LOINC codes (14979-9, 40100-0, 43734-3, 52123-7, 30323-0, 33890-5, 33891-3, 34189-1, 38276-2, 5946-9, 5950-1).

    Section: None

    Source: JIRA (CQM-1876)

  • Value set Partial Thromboplastin Time (2.16.840.1.113762.1.4.1045.25): Added 11 LOINC codes (14979-9, 40100-0, 43734-3, 52123-7, 30323-0, 33890-5, 33891-3, 34189-1, 38276-2, 5946-9, 5950-1).

    Section: None

    Source: JIRA (CQM-1909)

  • Value set Prothrombin Time (2.16.840.1.113762.1.4.1045.24): Added 1 LOINC code (5902-2).

    Section: None

    Source: JIRA (CQM-1824)

External Resources