Stroke/Transient Ischemic Attack (TIA)

In-hospital deaths per 1,000 hospital discharges with acute stroke as a principal diagnosis for patients ages 18 years and older. Includes metrics for discharges grouped by type of stroke. Excludes obstetric discharges and transfers to another hospital.

[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report in-hospital deaths per 1,000 hospital discharges.]

Proportion of patients with carotid artery stenting procedures who had follow up performed for evaluation of Vital Status and neurological assessment with an NIH Stroke Scale (by an examiner who is certified by the American Stroke
Association) occurring between day 21 and the end of day 75 after the procedure. (Days 21-75 inclusive)

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.

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.

Proportion of subarachnoid hemorrhage (SAH) patients age 18 years and older for whom nimodipine treatment was administered within 24 hours of arrival at this hospital.

This is the sixth 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.

This measure estimates a hospital-level, risk-standardized readmission rate (RSRR) of unplanned, all-cause readmission within 30 days of discharge from an index admission with an eligible condition or procedure. The measure reports a single summary RSRR, derived from the volume-weighted results of five different models, one for each of the following specialty cohorts based on groups of discharge condition categories or procedure categories: surgery/gynecology, general medicine, cardiorespiratory, cardiovascular, and neurology.

This measure estimates a hospital-level, risk-standardized readmission rate (RSRR) of unplanned, all-cause readmission within 30 days of discharge from an index admission with an eligible condition or procedure. The measure reports a single summary RSRR, derived from the volume-weighted results of five different models, one for each of the following specialty cohorts based on groups of discharge condition categories or procedure categories: surgery/gynecology, general medicine, cardiorespiratory, cardiovascular, and neurology.

This hybrid measure estimates a hospital-level, 30-day risk-standardized mortality rate (RSMR) for patients discharged from the hospital with a principal discharge diagnosis of acute ischemic stroke. Mortality is defined as death from any cause within 30 days of the index admission date for stroke patients.

This measure estimates a hospital-level, risk-standardized readmission rate (RSRR) of unplanned, all-cause readmission within 30 days of hospital discharge for any eligible condition. The measure reports a single summary RSRR, derived from the volume-weighted results of five different models, one for each of the following specialty cohorts based on groups of discharge condition categories or procedure categories: surgery/gynecology, general medicine, cardiorespiratory, cardiovascular, and neurology.

This measure estimates the mean risk-adjusted mean change in mobility score between admission and discharge for Inpatient Rehabilitation Facility (IRF) Medicare Part A and Medicare Advantage patients.