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Fall 2019

Carotid Artery Stenting: Evaluation of Vital Status and NIH Stroke Scale at Follow Up

  • 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)

    CBE ID
    2396

Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (PQI 05)

  • Admissions with a principal diagnosis of chronic obstructive pulmonary disease (COPD) or asthma per 100,000 population, ages 40 years and older. Excludes obstetric admissions and transfers from other institutions.

    [NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]

    CBE ID
    0275

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

  • 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.

    CBE ID
    2864

CSTK-03: Severity Measurement Performed for Subarachnoid Hemorrhage (SAH) and Intracerebral Hemorrhage (ICH) Patients (Overall Rate)

  • 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.

    CBE ID
    2866

CSTK-06: Nimodipine Treatment Administered

  • 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.

    CBE ID
    2863

Death Rate in Low-Mortality Diagnosis Related Groups (PSI02)

  • In-hospital deaths per 1,000 discharges for low mortality (< 0.5%) Diagnosis Related Groups (DRGs) among patients ages 18 years and older or obstetric patients. Excludes cases with trauma, cases with cancer, cases with an immunocompromised state, and transfers to an acute care facility.

    [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.]

    CBE ID
    0347

Diabetes Care for People with Serious Mental Illness: Blood Pressure Control (&lt;140/90 mm Hg)

  • The percentage of patients 18-75 years of age with a serious mental illness and diabetes (type 1 and type 2) whose most recent blood pressure (BP) reading during the measurement year is <140/90 mm Hg.

    Note: This measure is adapted from an existing health plan measure used in a variety of reporting programs for the general population (NQF #0061: Comprehensive Diabetes Care: Blood Pressure Control <140/90 mm Hg) which is endorsed by NQF and is stewarded by NCQA.

    CBE ID
    2606