eMeasure Title

Thrombolytic Therapy

eMeasure Identifier (Measure Authoring Tool) 91 eMeasure Version number 6.1.000
NQF Number 0437 GUID 2838875a-07b5-4bf0-be04-c3eb99f53975
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward The Joint Commission
Measure Developer The Joint Commission
Endorsed By National Quality Forum
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
Copyright
Measure specifications are in the Public Domain.

LOINC(R) is a registered trademark of the Regenstrief Institute.

This material contains SNOMED Clinical Terms (R) (SNOMED CT(C)) copyright 2004-2015 International Health Terminology Standards Development Organization. All rights reserved.
Disclaimer
These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty.
Measure Scoring Proportion
Measure Type Process
Measure Item Count
Encounter, Performed: Non-Elective Inpatient Encounter
Stratification
None
Risk Adjustment
None
Rate Aggregation
None
Rationale
The administration of thrombolytic agents to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials. These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA) approved the use of intravenous recombinant tissue plasminogen activator (IV r-tPA or t-PA) for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV t-PA in patients treated within 3 hours of symptom onset. While controversy still exists among some specialists, the major society practice guidelines developed in the United States all recommend the use of IV t-PA for eligible patients. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment.

The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better the patient outcome. Therefore, the target for IV t-PA initiation remains within 3 hours of time last known well. The administration of IV thrombolytic therapy beyond 3 hours of stroke symptom onset has not been FDA approved.
Clinical Recommendation Statement
The administration of thrombolytic agents to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials. Intravenous recombinant tissue plasminogen activator (IV r-tPA or t-PA) should be used for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset.
Improvement Notation
Improvement is noted as an increase in rate
Reference
del Zoppo GJ, Saver JL, Jauch EC, Adams HP. Expansion of the Time Window for Treatment of Acute Ischemic Stroke With Intravenous Tissue Plasminogen Activator: A Science Advisory From the American Heart Association/ American Stroke Association. Stroke. 2009;40:2945-2948.
Reference
Guyatt, G. H., E. A. Akl, M. Crowther, D. D. Gutterman, H. J. Schuunemann, Therapy American College of Chest Physicians Antithrombotic, and Panel Prevention of Thrombosis. "Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines." [In eng]. Chest 141, no. 2 Suppl (Feb 2012): 7S-47S.
Reference
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).
Reference
Kwiatkowski, T. G., R. B. Libman, M. Frankel, B. C. Tilley, L. B. Morgenstern, M. Lu, J. P. Broderick, et al. "Effects of Tissue Plasminogen Activator for Acute Ischemic Stroke at One Year. National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study Group." [In eng]. N Engl J Med 340, no. 23 (Jun 10 1999): 1781-7.
Reference
Saposnik, G., J. Fang, M. K. Kapral, J. V. Tu, M. Mamdani, P. Austin, S. C. Johnston, Network Investigators of the Registry of the Canadian Stroke, and Group Stroke Outcomes Research Canada Working. "The Iscore Predicts Effectiveness of Thrombolytic Therapy for Acute Ischemic Stroke." [In eng]. Stroke 43, no. 5 (May 2012): 1315-22.
Reference
"Tissue Plasminogen Activator for Acute Ischemic Stroke. The National Institute of Neurological Disorders and Stroke Rt-Pa Stroke Study Group." [In eng]. N Engl J Med 333, no. 24 (Dec 14 1995): 1581-7.
Reference
Wardlaw, J. M., V. Murray, E. Berge, and G. J. Del Zoppo. "Thrombolysis for Acute Ischaemic Stroke." [In eng]. Cochrane Database Syst Rev, no. 4 (2009): CD000213.
Definition
None
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.
Transmission Format
TBD
Initial 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
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
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
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Table of Contents


Population Criteria

Data Criteria (QDM Variables)

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables


Measure Set
eMeasure Stroke (eSTK)