Download ICD-9 CM Principal or Other Procedure Codes

Session A: Thursday, October 11, 2012
Repeated on Tuesday, October 16, 2012
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Comprehensive Stroke (CSTK)
Draft Measures
Pilot Test Training
Objectives
This slide presentation highlights key points and
abstraction guidelines only. Complete measure
specifications are provided with the data collection
tool and should be used for medical record
abstraction during the pilot test.
2
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Discuss the measure specifications, related
data elements, and algorithms (CSTK-01,
CSTK-03, CSTK-04, CSTK-04a, CSTK-04b,
and CSTK-06)
Provide opportunity for questions
Comprehensive Stroke Certification
Structure
DSC Standards +
PSC & CSC Standards
Quality & Safety of
Care for Stroke
Patients
Process
Outcome
On-site Review
STK Core + CSC
Measures
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CSC
Standardized Measure Identification
Process
Existing evidence-based
measures submitted by
public/stakeholders
Develop measure
specifications & data
collection tools
Expert Advisory Panel
review of submitted
measures &
recommendation of
candidate measures
Identify measure scope and
framework (domains of
care)
Public/Stakeholder
Comment re. candidate
measures
Expert Advisory Panel
meets
( identify additional
domains, endorse
framework, identify extant
measures)
Expert Advisory Panel
review of comment & final
recommendation of
measures
Pilot test and reliability
test of measures
Expert Advisory Panel
review of pilot results &
measure revision
Implementation of
measure set
Additional measures
solicited via 30 day public
comment period & via list
serves, etc.
Responsible entity:
TJC Staff
Expert Panel
Public/Stakeholders
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Determine measurement
topic
CSTK Initial Patient Population
 Same population as the STK core
measures
 Two types of stroke patients:
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1) Ischemic stroke patients (Appendix A,
Table 8.1)
2) Hemorrhagic stroke patients (Appendix A,
Table 8.2)
CSTK Initial Patient Population
The population of the CSTK measures is
identified using 4 data elements:
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– ICD-9-CM Principal Diagnosis Code
– Admission Date
– Birthdate
– Discharge Date
CSTK Initial Patient Population
–
–
–
ICD-9-CM Principal Diagnosis Code for
stroke
Patient Age (Admission Date minus
Birthdate) greater than or equal to 18
years
Length of Stay (Discharge Date minus
Admission Date) less than / = to 120 days
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 Patients admitted to the hospital for
inpatient care:
ICD-9-CM Principal Diagnosis Codes
Appendix A, Table 8.1 and Table 8.2
Last Updated: Version 3.2
Ischemic Stroke (STK)
Shortened Description
OCL BSLR ART W INFRCT
OCL CRTD ART WO INFRCT
OCL CRTD ART W INFRCT
OCL VRTB ART W INFRCT
OCL MLT BI ART W INFRCT
OCL SPCF ART W INFRCT
OCL ART NOS
CRBL THRMBS WO INFRCT
CRBL THRMBS
CRBL EMBLSM W INFRCT
CRBL ART OCL NOS
CVA
Last Updated: Version 3.2
Table 8.2
Code
430
431
Hemorrhagic Stroke (STK)
Shortened Description
SUBARACHNOID HEMORRHAGE
INTRACEREBRAL HEMORRHAGE
Specifications Manual for National Hospital Inpatient Quality Measures
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Table 8.1
Code
433.01
433.10
433.11
433.21
433.31
433.81
433.91
434.00
434.01
434.11
434.91
436
CSTK Initial Patient Population
STK Initial Patient Population
Algorithm
Start STK Initial Patient Population
logic sub-routine
ICD
Start
Variable Key:
Patient Age
Initial Patient Population Reject Case Flag
Length of Stay
Process all cases that have successfully reached the point in the
Transmission Data Processing Flow: Clinical which calls this Initial
Patient Population Algorithm. Do not process cases that have been rejected
before this point in the Transmission Data Processing Flow: Clinical.
ICD-9-CM
Principal Diagnosis
Code
Not on Table
8.1 and 8.2
On Table 8.1 or 8.2
Patient Age (in years) = Admission Date minus Birthdate
Use the month and day portion of admission date and birthdate to yield
the most accurate age
Patient
Age
< 18
years
>= 18 years
Length of Stay (in days) = Discharge Date
minus Admission Date
> 120 days
<= 120 days
Patient not in the
STK Initial Patient
Population
Patient is in the STK Initial Patient
Population
Patient is not eligible
to be sampled for the
STK measure set
Patient is eligible to be sampled for the
STK measure set
Set Initial Patient Population Reject
Case Flag = “No”
Return to
Transmission Data Processing
Flow: Clinical
(Data Transmission section)
Set Initial Patient
Population Reject
Case Flag = “Yes”
ICD
End
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Length of Stay
Excluded Populations – ALL
CSTK Measures
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Patients assigned an ICD-9-CM
Principal Diagnosis Code at discharge
that is not listed on Tables 8.1 or 8.2
Age < 18 years
Inpatient Discharges > 120 days
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Measures of Stroke Severity
CSTK-01 National Institutes of Health
Stroke Scale (NIHSS) Score Performed for
Ischemic Stroke Patients
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Denominator: Ischemic stroke patients who
arrive at this hospital emergency
department (ED)
Denominator: Included Populations
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Discharges with ICD-9-CM Principal
Diagnosis Code for ischemic stroke as
defined in Appendix A, Table 8.1
Patients less than 18 years of age
Patients who have a Length of Stay > 120
days
Patients admitted for Elective Carotid
Intervention
Patients who do not undergo recanalization
therapy and are discharged within 12 hours
of arrival at this hospital
Patients without warning signs and
symptoms of stroke on arrival at this hospital
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Denominator: Excluded Populations
Denominator: Data Elements
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Discharge Date
Discharge Time
ED Patient
Elective Carotid Intervention
ICD-9-CM Other Procedure Codes
ICD-9-CM Other Procedure Dates
ICD-9-CM Other Procedure Times
Denominator: Data Elements
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ICD-9-CM Principal Diagnosis Code
ICD-9-CM Principal Procedure Code
ICD-9-CM Principal Procedure Date
ICD-9-CM Principal Procedure Time
Warning Signs and Symptoms of Stroke
Discharge Time
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Collected For: CSTK-01, CSTK-03, CSTK-06
Definition: The documented time (military time)
the patient was discharged from acute care, left
against medical advice, or expired during this
stay.
Allowable Values: HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine
Discharge Time
Notes for Abstraction:
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– For times that include “seconds”, remove the
seconds and record the military time. Example:
15:00:35 would be recorded as 15:00.
– For patients who expire, the time that the patient
was pronounced / time of death should be used for
the discharge time.
– If the time of discharge is unable to be determined
from medical record documentation, select “UTD”.
Discharge Time
Suggested Data Sources:
Discharge summary
Face sheet
Nursing discharge notes
Physician orders
Progress notes
Transfer note
UB-04, Field Location: 6
Inclusion Guidelines for Abstraction:
– None
Exclusion Guidelines for Abstraction:
– None
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–
–
–
–
–
–
–
Collected For: CSTK-01
Definition: Documentation in the medical
record that the patient presented with warning
signs and symptoms of stroke at the time of
arrival to the hospital emergency department.
Stroke is a medical emergency. It is important
to recognize warning signs and symptoms of
stroke and initiate recanalization therapy when
indicated in order to prevent or minimize
infarction.
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Warning Signs and Symptoms of Stroke
Warning Signs and Symptoms of Stroke
– Y (Yes) There is documentation present in the
medical record that the patient presented with
warning signs and symptoms of stroke at the time of
arrival to the hospital emergency department.
– N (No) There was no documentation present in the
medical record that the patient presented with
warning signs and symptoms of stroke at the time of
arrival to the hospital emergency department, or
unable to determine from medical record
documentation.
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Allowable Values:
Warning Signs and Symptoms of Stroke
 Notes for Abstraction:
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– If documentation indicates that ANY warning signs or
symptoms were present at the time of the patient’s
arrival to the hospital emergency department, select
“Yes”.
Warning Signs and Symptoms of Stroke
–
–
–
–
–
–
–
–
–
–
–
–
Aphasia
Confusion
Dizziness
Dysarthria
Expressive aphasia
Headache
Hemianopia
Hemiparesis
Hemiparesthesia
Hemiplegia
Loss of balance
Loss of coordination
– Numbness or weakness
of the face, arm or leg
(unilateral or bilateral)
– Paresthesia (unilateral or
bilateral)
– Paralysis (unilateral or
bilateral)
– Receptive aphasia
– Syncope
– Trouble speaking
– Trouble understanding
– Trouble walking
– Vertigo
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Inclusion Guidelines for Abstraction:
Numerator: Ischemic stroke patients for
whom a NIHSS score is performed prior to
any acute recanalization therapy in
patients undergoing recanalization therapy
and documented in the medical record, OR
documented within 12 hours of hospital
arrival for patients who do not undergo
recanalization therapy.
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CSTK-01 National Institutes of Health
Stroke Scale (NIHSS) Score Performed for
Ischemic Stroke Patients
Patients with documented IA thrombolytic
(t-PA) therapy (ICD-9 CM Principal or Other
Procedure Codes as defined in Appendix A,
Table 8.1a AND Table 8.1b), OR
Patients with documented IV thrombolytic
(t-PA) therapy (ICD-9-CM Principal or Other
Procedure Codes as defined in Appendix A,
Table 8.1a ), OR
Patients with documented Mechanical
Endovascular Reperfusion Therapy (ICD-9
CM Principal or Other Procedure Codes as
defined in Appendix A, Table 8.1c)
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Numerator: Included Populations
ICD-9-CM Principal or Other Procedure
Code Tables 8.1a, 8.1b, and 8.1c
99.10
Table 8.1b
Code
38.91
Table 8.1c
Code
00.63
00.64
00.65
39.72
39.74
39.75
39.76
Thrombolytic Agent Procedures
Shortened Description
INJECTION OR INFUSION OF THROMBOLYTIC AGENT
Thrombolytic Agent Procedures
Shortened Description
ARTERIAL CATHETERIZATION
Mechanical Endovascular Reperfusion Procedures
Shortened Description
PERC INS CAROTID STENT
PERC INS EXTRACRAN STENT
PERC INS INTRACRAN STENT
ENDOVASC EMBOL HD/NK VES
ENDO REM OBS HD/NECK VES
ENDO EMB HD/NK BARE COIL
ENDO EM HD/NK, BIOAC COIL
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Table 8.1a
Code
Numerator: Data Elements
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Arrival Date
Arrival Time
Initial NIHSS Score Date
Initial NIHSS Score Performed
Initial NIHSS Score Time
Collected For: CSTK-01
Definition: Documentation of the first National
Instititutes of Health Stroke Scale (NIHSS)
score that was done at this hospital. The
NIHSS measures several aspects of brain
function, including consciousness, vision,
sensation, movement, speech, and language.
The NIHSS serves several purposes, but its
main use in clinical medicine is during the
assessment of whether or not the degree of
disability caused by a given stroke merits
treatment with t-PA. Score documentation may
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range from 0 to 42.
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Initial NIHSS Score Performed
Initial NIHSS Score Performed
Allowable Values:
– Y (YES) Initial NIHSS score was done at this
hospital.
– N (No) Initial NIHSS score was not done at this
hospital, OR Unable to determine (UTD) from the
medical record documentation.
– The NIHSS score may be documented by the
physician/APN/PA or nurse (RN).
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 Notes for Abstraction:
Initial NIHSS Score Performed
Suggested Data Sources:
Admitting note
Consultation form/note
Emergency room records
History and Physical
Nursing assessment
Nursing flow sheets
Progress notes
 Excluded Data Sources:
– Discharge summary
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–
–
–
–
–
–
–
CSTK-01 Algorithm Highlights
CSTK-01: National Institutes of Health Stroke Scale (NIHSS) Score Performed for Ischemic Stroke Patient
Denominator:
Ischemic stroke patients for whom a NIHSS score is performed prior to any acute recanalization therapy
in patients undergoing recanalization therapy and documented in the medical record, OR documented
within 12 hours of hospital arrival for patients who do not undergo recanalization therapy
Ischemic stroke patients who arrive at this hospital emergency department (ED)
Variable Key:
Timing I
Timing II
Timing III
START
Run cases that are included in the Stroke Initial Patient Population and pass the edits defined in the
Transmission Data Processing Flow: Clinical through this measure.
ICD-9-CM
Principal Diagnosis
Code
Not on Table 8.1
On Table 8.1
ED
Patient
Missing
=N
=Y
Missing
Elective Carotid
Intervention
=Y
=N
CSTK-01
X
Missng
Warning
Signs and Symptoms
of Stroke
=N
CSTK-01
B
=Y
CSTK-01
J
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Numerator:
CSTK-01
J
Missing
Initial
NIHSS Score
Performed
=N
=Y
Missing
Initial
NIHSS Score
Date
=UTD
= Non-UTD Value
Missing
Initial
NIHSS Score
Time
CSTK-01
D
= UTD
= Non-UTD Value
ICD-9-CM
Principal or Other Procedure
Code
All missing
or
None on Table
8.1a or 8.1b or 8.1c
CSTK-01
NR
Any on Table 8.1a or 8.1b or 8.1c
ICD-9-CM
Principal or Other Procedure
Code
None on Table 8.1b
ICD-9-CM
Principal or Other Procedure
Code
CSTK-01
X
None on Table 8.1a
ICD-9-CM
Principal or Other Procedure
Code
Any on Table 8.1a
Any on Table 8.1a or 8.1c
CSTK-01
K
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Any on Table 8.1b
CSTK-01
K
Missing
ICD-9-CM
Principal or Other Procedure
Date
= UTD
= Non-UTD Value
Missing
ICD-9-CM
Principal or Other Procedure
Time
= UTD
= Non-UTD Value
Timing I (in minute) =
ICD-9-CM Principal or Other Procedure Date and ICD-9-CM Principal or Other Procedure Time
minus
Initial NIHSS Score Date and Initial NIHSS Score Time
Timing I
< 0 minutes
CSTK-01
D
≥ 0 minutes
CSTK-01
E
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CSTK-01
X
CSTK-01
NR
Missing
Discharge
Date
= UTD
= Non-UTD Value
Missing
Discharge
Time
= UTD
= Non-UTD Value
Missing
Arrival
Date
= UTD
= Non-UTD Value
Missing
Arrival
Time
= UTD
= Non-UTD Value
Timing II (in minute) =
Discharge Date and Discharge Time
minus
Arrival Date and Arrival Time
< 0 minutes
≥ 0 and < 720
minutes
Timing II
CSTK-01
B
≥ 720 minutes
Timing III (in minute) =
Initial NIHSS Score Date and Initial NIHSS Score Time
minus
Arrival Date and Arrival Time
CSTK-01
X
X
Case Will
Be Rejected
Timing III
≥ 0 and ≤ 720
minutes
> 720 minutes
CSTK-01
E
E
In Numerator
Population
CSTK-01
B
CSTK-01
B
B
Not In Measure
Population
CSTK-01
D
D
In Measure
Population
STOP
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< 0 minutes
Monthly Sample Size
– Example: 55 ischemic stroke inpatient
discharges for the month of October.
Randomly select 15 records for review.
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Sampling allowed for CSTK-01 only
Sampling is an option and not required
Same methodology as STK core
measures
CSTK-01 Monthly Sample Size
Based on Initial Patient Population Size for the STK Measure Set
Average Monthly
Initial Patient Population
Size “N”
60
76-299
20% of Initial Patient Population size
15-75
15
< 15
No sampling; 100% Initial Patient Population
required
Specifications Manual for National Hospital Inpatient Quality Measures
36
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 300
Minimum Required
Sample Size
“n”
CSTK-03 Severity Measurement
Performed for SAH and ICH Patients
(Overall Rate)
– CSTK-03a and CSTK-03b are subsets of the
overall rate (CSTK-03), and stratified by the
type of stroke patient
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Denominator: SAH and ICH stroke patients
who arrive at this hospital emergency
department (ED)
Denominator: Included Populations
– with or without aneurysm repair procedure (ICD9-CM Principal or Other Procedure Code as
defined in Appendix A, Table 8.2d) OR
– surgical intervention procedure (ICD-9-CM
Principal or Other Procedure Code as defined in
Appendix A, Table 8.2e)
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Discharges with ICD-9-CM Principal
Diagnosis Code for hemorrhagic stroke as
defined in Appendix A, Table 8.2 (i.e., Table
8.2a and Table 8.2b)
ICD-9-CM Principal Diagnosis Code
Table 8.2a and Table 8.2b
Table 8.2a
Code
430
Table 8.2b
Code
431
Subarachnoid Hemorrhage
Shortened Description
Subarachnoid hemorrhage
Intracerebral Hemorrhage
Shortened Description
Intracerebral hemorrhage
Table 8.2a and Table 8.2b are subsets of the hemorrhagic
stroke initial patient population as detailed in Appendix A, Table 8.2 of
Table 8.2
Code
430
431
Hemorrhagic Stroke (STK)
Shortened Description
SUBARACHNOID HEMORRHAGE
INTRACEREBRAL HEMORRHAGE
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the Specifications Manual for National Hospital Inpatient Quality Measures.
ICD-9-CM Principal or Other Procedure
Code Table 8.2d
39.51
39.52
39.72
39.75
39.76
Aneurysm Repair Procedures
Shortened Description
CLIPPING OF ANEURYSM
ANEURYSM REPAIR
ENDOVASC EMBOL HD/NK VES
ENDO EMB HD/NK BARE COIL
ENDO EM HD/NK BIOAC COIL
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Table 8.2d
Code
ICD-9-CM Principal or Other Procedure
Code Table 8.2e
Code
00.61
00.62
00.63
00.64
00.65
01.01
01.09
01.10
01.23
01.24
01.39
02.01
02.03
02.04
02.05
02.06
02.07
02.21
38.02
38.12
38.22
38.30
38.31
38.32
38.42
39.28
39.53
39.74
Surgical Intervention Procedures
Shortened Description
PERC ANGIO EXTRACRAN VES
PERC ANGIO INTRACRAN VES
PERC INS CAROTID STENT
PERC INS EXTRACRAN STENT
PERC INS INTRACRAN STENT
CISTERNAL PUNCTURE
CRANIAL PUNCTURE NEC
INTRACRAN PRESSURE MONTR
REOPEN CRANIOTOMY SITE
OTHER CRANIOTOMY
OTHER BRAIN INCISION
LINEAR CRANIOTOMY
SKULL FLAP FORMATION
BONE GRAFT TO SKULL
SKULL PLATE INSERTION
CRANIAL OSTEOPLASTY NEC
SKULL PLATE REMOVAL
INSERT/REPLACE EVD
HEAD/NECK VES INCIS NEC
HEAD & NECK ENDARTER NEC
PERCUTANEOUS ANGIOSCOPY
VESSEL RESECT/ANAST NOS
INTRACRAN VES RESEC-ANAS
HEAD/NECK VES RESEC-ANAS
HEAD/NECK VES RESEC-REPL
EXTRACRAN-INTRACR BYPASS
ARTERIOVEN FISTULA REP
ENDO REM OBS HD/NECK VES
Complete table is not displayed.
41
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Table 8.2e
Patients less than 18 years of age
Patients who have a Length of Stay > 120
days
Non-surgical patients discharged within 6
hours of arrival at this hospital
Patients with admitting diagnosis of traumatic
brain injury (TBI), unruptured arteriovenous
malformation (AVM), and non-traumatic
subdural hematoma (ICD-9-CM Other
Diagnosis Codes as defined in Appendix A,
Table 8.2f)
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Denominator: Excluded Populations
Table 8.2f
Code
800.10
800.11
800.12
800.13
800.14
800.15
800.16
800.19
800.20
800.21
800.22
800.23
800.24
800.25
800.26
800.29
800.30
800.31
800.32
800.33
800.34
800.35
Traumatic Brain Injury
Shortened Description
CL SKL VLT FX/CEREBR LAC
CL SKULL VLT FX W/O COMA
CL SKULL VLT FX-BRF COMA
CL SKULL VLT FX-MOD COMA
CL SKL VLT FX-PROLN COMA
CL SKUL VLT FX-DEEP COMA
CL SKULL VLT FX-COMA NOS
CL SKL VLT FX-CONCUS NOS
CL SKL VLT FX/MENING HEM
CL SKULL VLT FX W/O COMA
CL SKULL VLT FX-BRF COMA
CL SKULL VLT FX-MOD COMA
CL SKL VLT FX-PROLN COMA
CL SKUL VLT FX-DEEP COMA
CL SKULL VLT FX-COMA NOS
CL SKL VLT FX-CONCUS NOS
CL SKULL VLT FX/HEM NEC
CL SKULL VLT FX W/O COMA
CL SKULL VLT FX-BRF COMA
CL SKULL VLT FX-MOD COMA
CL SKL VLT FX-PROLN COMA
CL SKUL VLT FX-DEEP COMA
Complete table is not displayed.
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ICD-9-CM Other Diagnosis Code
Table 8.2f
Discharge Date
Discharge Time
ED Patient
ICD-9-CM Other Procedure Codes
ICD-9-CM Other Procedure Dates
ICD-9-CM Other Procedure Times
ICD-9-CM Principal Diagnosis Code
ICD-9-CM Principal Procedure Code
ICD-9-CM Principal Procedure Date
ICD-9-CM Principal Procedure Time
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Denominator: Data Elements
Numerator: The number of SAH and ICH
stroke patients for whom a severity
measurement is performed prior to surgical
intervention in patients undergoing surgical
intervention and documented in the
medical record; OR documented within 6
hours of hospital arrival for patients who do
not undergo surgical intervention.
45
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CSTK-03 Severity Measurement Performed
for SAH and ICH Patients (Overall Rate)
Numerator: The number of SAH patients for
whom a Hunt and Hess Scale is performed
prior to surgical intervention in patients
undergoing surgical intervention and
documented in the medical record; OR
documented within 6 hours of hospital
arrival for patients who do not undergo
surgical intervention.
46
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CSTK-03a Hunt and Hess Scale Performed
for SAH Patients
Numerator: ICH stroke patients for whom a
ICH Score is performed prior to surgical
intervention in patients undergoing surgical
intervention and documented in the
medical record; OR documented within 6
hours of hospital arrival for patients who do
not undergo surgical intervention.
47
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CSTK-03b ICH Score Performed for ICH
Patients
Numerator: Data Elements
CSTK-03a
 Arrival Date
 Arrival Time
 Initial Hunt and
Hess Scale Date
 Initial Hunt and
Hess Scale
Performed
 Initial Hunt and
Hess Scale Time
CSTK-03b
 Arrival Date
 Arrival Time
 Initial ICH Score
Date
 Initial ICH Score
Performed

Initial ICH Score
Time
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CSTK-03
 Arrival Date
 Arrival Time
 Initial Hunt and
Hess Scale Date
 Initial Hunt and
Hess Scale
Performed
 Initial Hunt and
Hess Scale Time
 Initial ICH Score
Date
 Initial ICH Score
Performed
 Initial ICH Score
Time
Initial Hunt and Hess Scale Performed
49
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Collected For: CSTK-03
Definition: Documentation of the first Hunt and
Hess scale that was done at this hospital. The
Hunt and Hess scale is a grading system used
to classify the severity of a subarachnoid
hemorrhage based on the patient’s clinical
condition. The scale ranges from a score of 1
to 5. It is used as a predictor of
prognosis/outcome with a higher grade
correlating to a lower survival rate.
Initial Hunt and Hess Scale Performed
Allowable Values:
– Y (YES) Initial Hunt and Hess scale was done at this
hospital.
– N (No) Initial Hunt and Hess scale was not done at
this hospital, OR Unable to determine (UTD) from the
medical record documentation.
– Physician/APN/PA documentation of Hunt and Hess
scale only.
Excluded Data Sources:
– Discharge summary
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 Notes for Abstraction:
CSTK-03 Algorithm Highlights
CSTK-03:
Severity Measurement Performed for SAH and ICH Patients (Overall Rate)
Numerator:
The number of SAH and ICH stroke patients for whom a severity measurement is performed prior to
surgical intervention in patients undergoing surgical intervention and documented in the medical record;
OR documented within 6 hours of hospital arrival for patients who do not undergo surgical intervention
SAH and ICH stroke patients who arrive at this hospital emergency department (ED)
Denominator:
Variable Key
Timing I, Timing II
Timing III, Timing IV
Timing V
Stratification Table:
Set#
Stratified By *Principal Diagnosis Code
(Allowable Value)
CSTK03
Severity Measurement Performed
**
for SAH and ICH Patients
(Overall Rate)
CSTK-03a
Hunt and Hess Scale Performed
Table 8.2a
for SAH Patients
CSTK-03b
ICH Score Performed for ICH
Table 8.2b
Patients
START
Run cases that are included in the Stoke Initial Patient Population and pass the edits defined in the
Transmission Data Processing Flow: Clinical through this measure.
ICD-9-CM
Principal Diagnosis
Code
* This refers to the data element 'ICD-9-CM Principal Diagnosis Code’. Each case
will be stratified according to the principal diagnosis code, after the Category
Assignments are completed and the overall rate is calculated.
** No allowable value exists for the overall rate. It includes all diagnosis on Tables
8.2a to 8.2b.
Not on Table 8.2
On Table 8.2
ICD-9-CM
Other Diagnosis
Code
Any on Table 8.2f
CSTK-03
X
ED
Patient
=N
CSTK-03
B
=Y
ICD-9-CM
Principal or Other Procedure
Code
None on
Table 8.2d or Table 8.2e
CSTK-03
NS
Any on
Table 8.2d or Table 8.2e
CSTK-03
SG
51
© Copyright, The Joint Commission
All Missing or
None on Table 8.2f
CSTK-03
SG
CSTK-03
X
Missing
Initial
Hunt and Hess Scale
Performed
Initial
ICH Score
Performed
=N
=Y
=Y
Missing
Initial
Hunt and Hess Scale
Date
= UTD
Initial
ICH Score
Date
Missing
=Non-UTD Value
Missing
Initial
Hunt and Hess Scale
Time
ICD-9-CM
Principal or Other Procedure
Date
= UTD
Initial
ICH Score
Time
Missing
Missing
ICD-9-CM
Principal or Other Procedure
Time
= UTD
=Non-UTD Value
= UTD
ICD-9-CM
Principal or Other Procedure
Date
Missing
= Non-UTD Value
CSTK-03
X
= UTD
=Non-UTD Value
=Non-UTD Value
Missing
=N
= UTD
= Non-UTD Value
CSTK-03
X
= UTD
Missing
ICD-9-CM
Principal or Other Procedure
Time
= UTD
= Non-UTD Value
= Non-UTD Value
Timing I (in minute) =
ICD-9-CM Procedure Date and ICD-9-CM Procedure Time
minus
Initial Hunt and Hess Scale Date and Initial Hunt and Hess Scale Time
Timing II (in minute) =
ICD-9-CM Procedure Date and ICD-9-CM Procedure Time
minus
Initial ICH Score Date and Initial ICH Score Time
Timing I
< 0 minutes
CSTK-03
D
Timing II
< 0 minutes
CSTK-03
D
≥ 0 minutes
≥ 0 minutes
CSTK-03
E
52
© Copyright, The Joint Commission
Missing
CSTK-03
NS
Missing
Discharge
Date
= UTD
=Non-UTD Value
Missing
Discharge
Time
= UTD
= Non-UTD Value
Missing
Arrival
Date
= UTD
= Non-UTD Value
Missing
Arrival
Time
= UTD
CSTK-03
D
= Non-UTD Value
CSTK-03
X
< 0 minutes
Timing III
≥ 0 and < 360
minutes
CSTK-03
B
≥ 360
minutes
CSTK-03
NS1
53
© Copyright, The Joint Commission
Timing III (in minute) =
Discharge Date and Discharge Time
minus
Arrival Date and Arrival Time
CSTK-03
NS1
CSTK-03
X
Missing
Initial
Hunt and Hess Scale
Performed
Initial
ICH Score
Performed
=N
=Y
Missing
=Y
Initial
Hunt and Hess Scale
Date
= UTD
Missing
= Non-UTD Value
Missing
=N
Initial
Hunt and Hess Scale
Time
Initial
ICH Score
Date
= UTD
= Non-UTD Value
Missing
= UTD
Initial
ICH Score
Time
= UTD
= Non-UTD Value
= Non-UTD Value
Timing IV (in minute) =
Initial Hunt and Hess Scale Date and Initial Hunt and Hess Scale Time
minus
Arrival Date and Arrival Time
Timing V (in minute) =
Initial ICH Score Date and Initial ICH Score Time
minus
Arrival Date and Arrival Time
<0
minutes
Timing IV
≥ 0 and ≤ 360
minutes
CSTK-03
X
X
Case Will
Be Rejected
CSTK-03
X
> 360
minutes
CSTK-03
D
CSTK-03
X
< 0
minutes
> 360
minutes
Timing V
≥ 0 and ≤ 360
minutes
CSTK-03
B
CSTK-03
E
B
E
Not In Measure
Population
In Numerator
Population
CSTK-03
D
CSTK-03
D
D
In Measure
Population
CSTK-03
ab
54
© Copyright, The Joint Commission
Missing
CSTK-03
ab
Initialize the Measure Category Assignment for each strata measure (CSTK-03a and CSTK03b) = 'B'.
Do not change the Measure Category Assignment that was already calculated for the overall measure (CSTK-03).
The rest of the algorithm will reset the appropriate Measure Category Assignment to each strata measure
Overall Rate
Category Assignment
= B,X
Set the Measure Category Assignment for strata
measures
CSTK-03a and CSTK03b = ‘B’
On Table 8.2a
Set Measure Category Assignment
for strata measure CSTK-03a
=
Measure Category Assignment
for measure CSTK-03
On Table 8.2b
Set Measure Category Assignment
for strata measure CSTK-03b
=
Measure Category Assignment
for measure CSTK-03
= D, E
ICD-9-CM
Principal or Other Procedure
Code
ICD-9-CM
Principal or Other Procedure
Code
STOP
55
© Copyright, The Joint Commission
Not on Table 8.2a
© Copyright, The Joint Commission
Treatment Measures
CSTK-04 INR Reversal Achieved
57
© Copyright, The Joint Commission
Denominator: ICH stroke patients treated
with a procoagulant reversal agent at this
hospital
Denominator: Included Populations
58
© Copyright, The Joint Commission
Discharges with ICD-9-CM Principal
Diagnosis Code for hemorrhagic stroke as
defined in Appendix A, Table 8.2 AND
Patients who have an Admitting Diagnosis of
primary parenchymal ICH AND
INR > 1.4 performed closest to hospital
arrival
Patients less than 18 years of age
Patients who have a Length of Stay > 120
days
Patients with Comfort Measures Only
documented on day of or after hospital
arrival
Patients enrolled in clinical trials
Patients with a documented Reason for Not
Achieving an INR Value < 1.4
59
© Copyright, The Joint Commission
Denominator: Excluded Populations
Admitting Diagnosis
Clinical Trial
Comfort Measures Only
Discharge Date
ICD-9-CM Principal Diagnosis Code
Initial INR Value > 1.4
Procoagulant Reversal Agent Initiation
Reason for Not Achieving an INR Value < 1.4
60
© Copyright, The Joint Commission
Denominator: Data Elements
Admitting Diagnosis
– Any valid ICD-9-CM diagnosis code
61
© Copyright, The Joint Commission
Collected For: CSTK-04, CSTK-04a, CSTK04b
 Definition: The International Classification of
Diseases, Ninth Revision, Clinical Modification
(ICD-9-CM) code associated with the diagnosis
established at the time of the patient’s
admission to the hospital.
Allowable Values:
Admitting Diagnosis
 Notes for Abstraction:
– The admitting diagnosis is defined as the initial
working diagnosis documented by the patient’s
admitting or attending physician who determined that
inpatient care was necessary.
–
–
–
–
Admission form
Code List
Face Sheet
Problem List
62
© Copyright, The Joint Commission
Suggested Data Sources: ONLY acceptable
data source:
Collected For: CSTK-04, CSTK-04a
 Definition: Documentation that the
international normalized ratio (INR) value
performed closest to hospital arrival was
greater than or equal to 1.4. This value
correlates to the ability of the blood to clot.
Higher values greater than or equal to 1.4 are
associated with an increased risk of
hemorrhage.
63
© Copyright, The Joint Commission
Initial INR Value > 1.4
Initial INR Value > 1.4
Allowable Values:
 Notes for Abstraction:
– To determine the value for this data element, review
the INR values obtained closest to hospital arrival. If
any result is greater than or equal to 1.4, select
“Yes”.
64
© Copyright, The Joint Commission
– Y (YES) There is documentation that the INR value
performed closest to hospital arrival was greater than
or equal to 1.4.
– N (No) There is no documentation that the INR value
performed closest to hospital arrival was greater than
or equal to 1.4, OR unable to determine from medical
record documentation.
Procoagulant Reversal Agent Initiation
65
© Copyright, The Joint Commission
Collected For: CSTK-04, CSTK-04a, CSTK04b
 Definition: A procoagulant reversal agent was
initiated at this hospital. Procoagulant
reversal agents are medications that increase
coagulation factors to promote clotting.
Procoagulant Reversal Agent Initiation
Allowable Values:
66
© Copyright, The Joint Commission
– Y (YES) A procoagulant reversal agent was initiated
at this hospital.
– N (No) A procoagulant reversal agent was not
initiated at this hospital, OR unable to determine from
medical record documentation.
Procoagulant Reversal Agent Initiation
 Notes for Abstraction:
67
© Copyright, The Joint Commission
– If a procoagulant reversal agent was initiated at this
hospital, select “Yes”.
– Only accept reversal agents identified in the list
of inclusions. No other terms for reversal agents
will be accepted.
– If Vitamin K only was administered as the sole form
of reversal and no other procoagulant agent was
administered, select “No”.
Procoagulant Reversal Agent Initiation
Inclusion Guidelines for Abstraction:
– Fresh frozen plasma
(FFP)
– NovoSeven
– NovoSeven RT
– Profilnine SD
– Proplex T
– Prothrombin complex
concentrates (PCCs)
– rFVIIa
68
© Copyright, The Joint Commission
– Activated prothrombin
complex concentrates
– Anti-inhibitor coagulant
complex
– Autoplex T
– Bebulin VH
– Eptacog alfa
– Factor IX Complex
– Factor VIIa
(Recombinant)
– Feiba VH Immuno
Procoagulant Reversal Agent Initiation
Exclusion Guidelines for Abstraction:
69
© Copyright, The Joint Commission
– Vitamin K Only
– Factor IX (without
complex)
Reason for Not Achieving an INR Value
< 1.4
Collected For: CSTK-04
 Definition: Reason for not achieving an INR
value < 1.4
70
© Copyright, The Joint Commission
– Adverse reaction to a procoagulant reversal agent
– Other reasons documented by physician/advanced
practice nurse/physician assistant
(physician/APN/PA)
Reason for Not Achieving an INR Value
< 1.4
Allowable Values:
71
© Copyright, The Joint Commission
– Y (YES) There is documentation of a reason for not
achieving an INR value < 1.4.
– N (No) There is no documentation of a reason for
not achieving an INR value < 1.4, OR unable to
determine from medical record documentation.
Reason for Not Achieving an INR Value
< 1.4
72
© Copyright, The Joint Commission
 Notes for Abstraction:
– Reasons for not achieving an INR value < 1.4
must be documented by the
physician/APN/PA.
– If reasons are not mentioned in the
context of an INR value, do not make
inferences (e.g., do not assume that an INR
value < 1.4 was not achieved because of an
adverse reaction to a procoagulant reversal
agent unless documentation explicitly states
so.)
Reason for Not Achieving an INR Value
< 1.4
73
© Copyright, The Joint Commission
 Notes for Abstraction:
– Reasons must be explicitly documented (e.g.,
“Last INR 1.6. NovoSeven stopped after
patient developed DIC.”; “Patient with H/O
bovine allergy. INR ↓ 1. 4 after FFP.)
– When conflicting information is documented
in the medical record, select “Yes”.
CSTK-04 INR Reversal Achieved
74
© Copyright, The Joint Commission
Numerator: ICH stroke patients who achieve
an INR value < 1.4 post-treatment
Numerator: Data Elements
75
© Copyright, The Joint Commission
INR Value < 1.4
INR Value < 1.4
76
© Copyright, The Joint Commission
Collected For: CSTK-04, CSTK-04b
 Definition: Documentation of an international
normalized ratio (INR) value less than 1.4
following initiation of a procoagulant
reversal agent. This value correlates to the
ability of the blood to clot.
INR Value < 1.4
Allowable Values:
 Notes for Abstraction:
© Copyright, The Joint Commission
– Y (YES) There is documentation of of an INR result
less than 1.4 following initiation of a procoagulant
reversal agent.
– N (No) There is no documentation of an INR result
less than 1.4 following initiation of a procoagulant
reversal agent, OR unable to determine from medical
record documentation.
– To determine the value for this data element, review
the INR results obtained after the initiation of a
procoagulant reversal agent. If any result is less than
1.4, select “Yes”.
77
Continuous Variable Statement: Time (in
minutes) from hospital arrival to initiation of
treatment with a procoagulant reversal
agent in patients with an admitting
diagnosis of primary parenchymal ICH and
an initial INR > 1.4.
78
© Copyright, The Joint Commission
CSTK-04a Median Time to Treatment with
a Procoagulant Reversal Agent
Discharges with ICD-9-CM Principal
Diagnosis Code for hemorrhagic stroke as
defined in Appendix A, Table 8.2. AND
Patients who have an Admitting Diagnosis of
primary parenchymal ICH AND
INR > 1.4 performed closest to hospital
arrival AND
Procoagulant Reversal Agent Initiation
performed at this hospital
79
© Copyright, The Joint Commission
Included Populations
Excluded Populations
80
© Copyright, The Joint Commission
Patients less than 18 years of age
Patients who have a Length of Stay > 120
days
Patients with Comfort Measures Only
documented on day of or after hospital
arrival
Patients enrolled in clinical trials
Admitting Diagnosis
Arrival Date
Arrival Time
Clinical Trial
Comfort Measures Only
Discharge Date
ICD-9-CM Principal Diagnosis Code
Initial INR Value > 1.4
Procoagulant Reversal Agent Initiation
Procoagulant Reversal Agent Initiation Date
Procoagulant Reversal Agent Initiation Time81
© Copyright, The Joint Commission
Data Elements
CSTK-04b Median Time to INR Reversal
82
© Copyright, The Joint Commission
Continuous Variable Statement: Time (in
minutes) from procoagulant reversal
initiation at this hospital to first INR value <
1.4 in patients with an admitting diagnosis
of primary parenchymal ICH
Discharges with ICD-9-CM Principal
Diagnosis Code for hemorrhagic stroke as
defined in Appendix A, Table 8.2. AND
Patients who have an Admitting Diagnosis of
primary parenchymal ICH AND
INR < 1.4 following initiation of a
procoagulant reversal agent AND
Procoagulant Reversal Agent Initiation
performed at this hospital
83
© Copyright, The Joint Commission
Included Populations
Excluded Populations
84
© Copyright, The Joint Commission
Patients less than 18 years of age
Patients who have a Length of Stay > 120
days
Patients with Comfort Measures Only
documented on day of or after hospital
arrival
Patients enrolled in clinical trials
Admitting Diagnosis
Clinical Trial
Comfort Measures Only
Discharge Date
INR Value < 1.4
INR Value < 1.4 Date
INR Value < 1.4 Time
ICD-9-CM Principal Diagnosis Code
Procoagulant Reversal Agent Initiation
Procoagulant Reversal Agent Initiation Date
Procoagulant Reversal Agent Initiation Time85
© Copyright, The Joint Commission
Data Elements
CSTK-04 Algorithm Highlights
CSTK-04: INR Reversal Achieved
Numerator Statement: ICH stroke patients who achieve an INR value < 1.4 post-treatment
Denominator Statement: ICH stroke patients treated with a procoagulant agent
START
Run cases that are included in the Stroke Initial Patient Population and pass the edits defined in the
Transmission Data Processing Flow: Clinical through this measure.
ICD-9-CM
Principal Diagnosis
Code
Not on Table 8.2
On Table 8.2
Missing
Initial
INR Value > 1.4
Missing
Clinical
Trial
=N
=Y
=Y
=N
Missing
Comfort
Measures
Only
=1
= 2, 3, 4
Missing
Admitting
Diagnosis
Not on Table 8.2c
On Table 8.2c
Missing
Procoagulant
Reversal Agent
Initiation
=N
CSTK-04
X
Missing
CSTK-04
X
Missing
INR Value < 1.4
=Y
X
Case Will
Be Rejected
E
In Numerator
Population
=N
Reason
for Not Achieving an INR
Value < 1.4
=N
CSTK-04
B
=Y
CSTK-04
B
D
In Measure
Population
B
Not In Measure
Population
STOP
86
© Copyright, The Joint Commission
= Y
CSTK-04a Algorithm Highlights
CSTK-04a: Median Time to Treatment with a Procoagaulant Reversal Agent
Continuous Variable Statement:
Time (in minutes) from hospital arrival to initiation of treatment with a procoagulant
reversal agent in patients with an admitting diagnosis of primary parenchymal ICH
and INR > 1.4
START
Run cases that are included in the Stroke Initial Patient Population and pass the edits defined in the
Transmission Data Processing Flow: Clinical through this measure.
ICD-9-CM
Principal Diagnosis
Code
Not on Table 8.2
On Table 8.2
Missing
Initial
INR Value > 1.4
=N
=Y
Missing
Clinical
Trial
=Y
=N
Missing
Comfort
Measures
Only
=1
Missing
Admitting
Diagnosis
Not on Table 8.2c
On Table 8.2c
CSTK-04a
X
Missing
Procogulant
Reversal Agent
Initiation
=N
CSTK-04a
B
=Y
CSTK-04a
J
87
© Copyright, The Joint Commission
= 2, 3, 4
CSTK-04a
J
Procogulant
Reversal Agent Initiation
Date
Missing
= UTD
=Non-UTD Value
Procogulant
Reversal Agent Initiation
Time
Missing
= UTD
=Non-UTD Value
Arrival
Date
Missing
= UTD
=Non-UTD Value
Arrival
Time
Missing
= UTD
=Non-UTD Value
Measurement Value (in minute) =
Procogulant Reversal Agent Initiation Date and Procogulant Reversal Agent Initiation Time
minus
Arrival Date and Arrival Time
CSTK-04a
X
<0
Y
In Measure
Population
Measurement
Value
≥0
CSTK-04a
B
D
Not In Measure
Population
In Measure
Population
B
STOP
Note: There will be no category assignment E for
this measure because it is a continuous variable.
88
© Copyright, The Joint Commission
X
Case Will
Be Rejected
CSTK-04b Algorithm Highlights
CSTK-04b: Median Time to INR Reversal
Continuous Variable Statement:
Time (in minutes) from procoagulant reversal initiation to first INR value < 1.4 in
patients with an admitting diagnosis of primary parenchymal ICH
START
Run cases that are included in the Stroke Initial Patient Population and pass the edits defined in the
Transmission Data Processing Flow: Clinical through this measure.
ICD-9-CM
Principal Diagnosis
Code
Not on Table 8.2
On Table 8.2
Missing
INR
Value < 1.4
=N
=Y
Missing
Clinical
Trial
=Y
=N
Missing
Comfort
Measures
Only
=1
Missing
Admitting
Diagnosis
Not on Table 8.2c
On Table 8.2c
CSTK-04b
X
Missing
Procogulant
Reversal Agent
Initiation
=N
CSTK-04b
B
=Y
CSTK-04b
J
89
© Copyright, The Joint Commission
= 2, 3, 4
CSTK-04b
J
Procogulant
Reversal Agent Initiation
Date
Missing
= UTD
=Non-UTD Value
Procogulant
Reversal Agent Initiation
Time
Missing
= UTD
=Non-UTD Value
INR Value < 1.4
Date
Missing
= UTD
=Non-UTD Value
INR Value < 1.4
Time
Missing
= UTD
=Non-UTD Value
Measurement Value (in minute) =
INR Value < 1.4 Date and INR Value < 1.4 Time
minus
Procoagulant Reversal Agent Initiation Date and Procoagulant Reversal Agent Initiation Time
CSTK-04b
X
<0
Y
In Measure
Population
Measurement
Value
≥0
CSTK-04b
B
D
Not In Measure
Population
In Measure
Population
B
STOP
Note: There will be no category assignment E for
this measure because it is a continuous variable.
90
© Copyright, The Joint Commission
X
Case Will
Be Rejected
CSTK-06 Nimodipine Treatment
Administered
91
© Copyright, The Joint Commission
Denominator: SAH patients
Denominator: Included Populations
92
© Copyright, The Joint Commission
Discharges with ICD-9-CM Principal
Diagnosis Code for subarachnoid
hemorrhage as defined in Appendix A, Table
8.2a.
Patients less than 18 years of age
Patients who have a Length of Stay > 120
days
Patients with Comfort Measures Only
documented on day of or after hospital
arrival
Patients enrolled in clinical trials
Patients discharged within 24 hours of arrival
at this hospital
93
© Copyright, The Joint Commission
Denominator: Excluded Populations
Denominator: Data Elements
94
© Copyright, The Joint Commission
Clinical Trial
Comfort Measure Only
Discharge Date
Discharge Time
ICD-9-CM Principal Diagnosis Code
CSTK-06 Nimodipine Treatment
Administered
95
© Copyright, The Joint Commission
Numerator: SAH patients for whom
nimodipine treatment was administered
within 24 hours of arrival at this hospital.
Numerator: Data Elements
96
© Copyright, The Joint Commission
Arrival Date
Arrival Time
Nimodipine Administration
Nimodipine Administration Date
Nimodipine Administration Time
Reason for Not Administering Nimodipine
Treatment
Collected For: CSTK-06
 Definition: Documentation that nimodipine
was administered at this hospital. Nimodipine
is a cerebroselective calcium channel blocker
that inhibits calcium transport into vascular
smooth muscle cells, thereby suppressing
contractions. Nimodipine is used in the
treatment of subarachnoid hemorrhage patients
to prevent or limit the severity of cerebral
vasospasm.
97
© Copyright, The Joint Commission
Nimodipine Administration
Nimodipine Administration
Allowable Values:
98
© Copyright, The Joint Commission
– Y (YES) Nimodipine was administered at this
hospital.
– N (No) Nimodipine was not administered at this
hospital,OR unable to determine from medical record
documentation.
Nimodipine Administration
 Notes for Abstraction:
99
© Copyright, The Joint Commission
– Nimodipine treatment must be administered at this
hospital in order to select “Yes”.
– If nimodipine was administered at another hospital
and the patient was subsequently transferred to this
hospital and nimodipine treatment continued on
admission to this hospital, select “Yes”.
– If nimodipine was administered at another hospital
and the patient was subsequently transferred to this
hospital and nimodipine treatment was not resumed
or discontinued, select “No”.
– A physician order for nimodipine that is not executed,
select “No”.
Nimodipine Administration
 Inclusion Guidelines for Abstraction:
– Nimodipine
– Nimotop
Exclusion Guidelines for Abstraction:
100
© Copyright, The Joint Commission
– All other calcium channel blocker medications other
than those listed as inclusions.
Nimodipine Administration Time
101
© Copyright, The Joint Commission
Collected For: CSTK-06
Definition: The time (military time) for which the
first dose of nimodipine was administered to a
patient with subarachnoid hemorrhage at this
hospital. Nimodipine inhibits calcium transport
into vascular smooth muscle cells, thereby
preventing or limiting cerebral vasospasm.
Nimodipine Administration Time
 Notes for Abstraction:
102
© Copyright, The Joint Commission
– Use the time at which initiation of nimodipine
administration was first documented. If a discrepancy
exists in time documentation from different sources,
choose the earliest time. If there are two or more
different nimodipine administration times (either
different nimodipine episodes or corresponding with
the same episode), enter the earliest time.
Reason for Not Administering Nimodipine
Treatment
Notes for Abstraction:
© Copyright, The Joint Commission
– Reasons for not administering nimodipine must be
documented by the physician/APN/PA or pharmacist
within 24 hours of hospital arrival. It is not
necessary to review documentation outside of this
timeframe.
– Documentation that the patient is NPO or has a
nasogastric tube (NGT) without mention that
nimodipine should not be administered is insufficient.
Do not infer that nimodipine is not needed unless
explicitly documented.
– Physician orders for “NPO except medications”
does not count as a reason for not administering
nimodipine, select “No”.
103
CSTK-06 Algorithm Highlights
CSTR-06:
Nimodipine Treatment Administered
Numerator:
SAH patients for whom nimodipine treatment was administered within 24 hours
of arrival at this hospital
SAH patients
Denominator:
START
Run cases that are included in the Global Initial Patient Population and pass the edits defined in the
Transmission Data Processing Flow: Clinical through this measure.
ICD-9-CM
Principal Diagnosis
Code
Variable Key:
Timing I
Timing II
Not on Table 8.2a
On Table 8.2a
Missing
Clinical
Trial
=Y
=N
Missing
Comfort
Measures
Only
=1
CSTK-06
B
= 2, 3, 4
Missing
Arrival
Date
= UTD
Non-UTD Value
Arrival
Time
= UTD
Non-UTD Value
Missing
Discharge
Date
= UTD
Non-UTD Value
CSTK-06
X
Missing
Discharge
Time
= UTD
CSTK-06
D
Non-UTD Value
CSTK-06
J
104
© Copyright, The Joint Commission
Missing
CSTK-06
J
Timing I (in minute) =
Discharge Date and Discharge Time
minus
Arrival Date and Arrival Time
<0
≥ 0 and < 1440
minutes
Timing I
CSTK-06
X
≥ 1440 minutes
Missing
Missing
Nimodipine
Administration
Reason
for Not Administering
Nimodipine
Treatment
= N
=Y
Missing
=Y
CSTK-06
E
=N
Nimodipine
Administration
Date
= UTD
Non-UTD Value
Missing
Nimodipine
Administration
Time
= UTD
Non-UTD Value
<0
CSTK-06
X
X
CSTK-06
X
Case Will
Be Rejected
> 1440
minutes
Timing II
≥ 0 and ≤ 1440
minutes
E
CSTK-06
E
In Numerator
Population
CSTK-06
D
D
In Measure
Population
CSTK-06
B
B
Not In Measure
Population
STOP
105
© Copyright, The Joint Commission
Timing II (in minute) =
Nimodipine Administration Date and Nimodipine Administration Time
minus
Arrival Date and Arrival Time
Session B, October 12, 2012
to be continued…….
106
© Copyright, The Joint Commission
Discuss the measure specifications, related
data elements, and algorithms (CSTK-05,
CSTK-07, CSTK-07a, and CSTK-02)
Review the data collection tool
Provide opportunity for questions
© Copyright, The Joint Commission
107