Proportion of SAH and ICH stroke patients age 18 years or older for whom a severity measurement (i.e., Hunt and Hess Scale for SAH patients or ICH Score for ICH patients) is performed prior to surgical intervention (e.g., clipping, coiling, or any surgical intervention) in patients undergoing surgical intervention and documented in the medical record; OR, documented within 6 hours of arrival at the hospital emergency department in patients who do not undergo surgical intervention.
This is the third measure 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
Numerator
CSTK-03 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 arrival at the hospital emergency department in patients who do not undergo surgical intervention.
CSTK-03a The number of SAH stroke 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 arrival at the hospital emergency department in patients who do not undergo surgical intervention.
CSTK-03b The number of ICH stroke patients for whom an 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 arrival at the hospital emergency department in patients who do not undergo surgical intervention.
Denominator
SAH and ICH 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
• 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)
• Patients who have an ICD-10-CM Principal Diagnosis Code in Appendix A, Table 8.2a Subarachnoid Hemorrhage assigned at discharge and documentation of non-aneurysmal SAH or SAH related to head trauma any time during the hospital stay
Measure Record
Point of Contact
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