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 TypeElectronic Clinical Quality Measure (eCQM)Care SettingNumerator
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.DenominatorSAH 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 stayTesting Data Sources
- Measure StructureClinical Condition Topic AreaNon Condition SpecificTarget PopulationMeasure Selection AttributesNational Quality Strategy PrioritiesClinical Preventive ServicesHealth and Well-Being
- Risk Adjustment
- Current or planned use(s)
- Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed Neurology Fall Cycle 2019Initial EndorsementEndorsement StatusLast UpdatedRemoval Date
- StewardSteward Organization EmailSteward Organization Copyright
No royalty or use fee is required for copying or reprinting this manual, but the following are required as a condition of usage: 1) disclosure that the Specifications Manual is periodically updated, and that the version being copied or reprinted may not be up-to-date when used unless the copier or printer has verified the version to be up-to-date and affirms that, and 2) users participating in Joint Commission accreditation, including ORYX® vendors, are required to update their software and associated documentation based on the published manual production timelines.