Proportion of ischemic stroke patients age 18 years or older for whom an initial NIHSS score is performed prior to any acute recanalization therapy (i.e., intra-venous (IV) thrombolytic (t-PA) therapy, or intra-arterial (IA) thrombolytic (t-PA) therapy, or mechanical endovascular reperfusion (MER) therapy) in patients undergoing recanalization therapy and documented in the medical record, or documented within 12 hours of arrival at the hospital emergency department in patients who do not undergo recanalization therapy.
This is the first in a set of measures developed for Joint Commission Comprehensive Stroke Certification. Although it is not required that these measures are reported in conjunction with each other, The Joint Commission develops measures in sets in order to provide as comprehensive a view of quality for a particular clinical topic as possible.
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.9 Care Setting1.20 Testing Data Sources
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1.14 Numerator
Ischemic stroke patients for whom an initial 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 arrival at the hospital emergency department in patients who do not undergo recanalization therapy.
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1.15 Denominator
Ischemic stroke patients.
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Exclusions
• Patients less than 18 years of age
• Patients who have a Length of Stay greater than 120 days
• Patients with Comfort Measures Only documented on the day of or day after hospital arrival
• Patients admitted for Elective Carotid Intervention
• Patients who do not undergo recanalization therapy and are discharged within 12 hours of arrival at this hospital
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Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed Neurology Fall Cycle 2019Initial EndorsementLast UpdatedRemoval Date
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StewardThe Joint CommissionSteward Organization POC EmailSteward Organization Copyright
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Risk Adjustment
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