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CSTK-01: National Institutes of Health Stroke Scale (NIHSS) Score Performed for Ischemic Stroke Patients

CBE ID
2864
1.5 Project
Endorsement Status
1.0 New or Maintenance
1.1 Measure Structure
Previous Endorsement Cycle
Is Under Review
No
1.6 Measure Description

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.

    Measure Specs
      General Information
      1.7 Measure Type
      1.3 Electronic Clinical Quality Measure (eCQM)
      1.8 Level of Analysis
      1.9 Care Setting
      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.

      1.15 Denominator

      Ischemic stroke patients.

      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

      Most Recent Endorsement Activity
      Measure Retired and Endorsement Removed Neurology Fall Cycle 2019
      Initial Endorsement
      Last Updated
      Removal Date
      Steward Organization
      The Joint Commission
      Steward POC email
      Steward Organization Copyright

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