Performance measure summary reports

Attachment 11_Table shells of performance measure reports.docx

Paul Coverdell National Acute Stroke Program (PCNASP) Reporting System

Performance measure summary reports

OMB: 0920-1108

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Paul Coverdell National Acute Stroke Registry Quarterly Performance Measure Results




Number of Hospitals:






Demographic

N*

Percent*

Age

 

 

18-34

 

 

35-44

 

 

45-54

 

 

55-64



65-74

 

 

75-84



85+



Race

 

 

Non-Hispanic White

 

 

Non-Hispanic Black

 

 

Hispanic



Other



Unknown



Gender

 

 

Missing

 

 

Male

 

 

Female

 

 


 

 




Arrival Mode

N*

Percent*

EMS

 

 

Private Auto

 

 

Transfer From Another Hospital

 

 

ND/Unknown

 

 




Type

N*

Percent*

Ischemic

 

 

ICH

 

 

SAH

 

 

TIA

 

 

Ill-Defined (SNS)

 

 

No stroke

 

 

Missing

 

 




Alteplase (tPA)

N*

Percent*

All IS Patients receiving any tPA

 

 

All IS tPA patients having symptomatic ICH complications



All IS tPA patients having life threatening complications



Door to needle time <=45 minutes



Mean Door to Needle Time (hours)



Median Door to Needle Time (hours)



Mean LKW to Needle Time (hours)



Median LKW to Needle Time (hours)





TIA only & SNS only

N*

Percent*

TIA Patients who received any tPA

 

 

SNS Patients who received any tPA





 

 

 

 

 

 

 

 

 



Coverdell In-Hospital Performance Measures Numerator*

Denominator*

Percent*

HS/SNS

IS

TIA



Alteplase (tPA) Given

 

 

 

 

X

 



Dysphagia Screening

 

 

 

X

X

 



VTE/DVT Prophylaxis by end of Day 2

 

 

 

X

X

 



Antithrombotic Therapy by end of Day 2

 

 

 


X

X



Assessed for Rehabilitation

 

 

 

X

X

 



Stroke Education

 

 

 

X

X

X



Smoking Cessation Counseling

 

 

 

X

X

X



Antithrombotic Therapy at Discharge

 

 

 


X

X



Statin Therapy at Discharge

 

 

 


X

X



Anticoagulation for Atrial Fibrillation

 

 

 


X

X



Doo to needle (IV tPA) time in 60 minutes

 

 

 


X

 



NIH stroke scale score recorded

 

 

 

 

X

 














Ischemic Stroke Only

 

 

Numerator*

Denominator*

Percent*

White*

Race Other*

Male*

Female*


Alteplase (tPA) Given

 

 

 

 

 

 

 


Dysphagia Screening

 

 

 

 

 

 

 


VTE/DVT Prophylaxis by end of Day 2

 

 

 

 

 

 

 


Antithrombotic Therapy by end of Day 2

 

 

 

 

 

 

 


Assessed for Rehabilitation

 

 

 

 

 

 

 


Stroke Education

 

 

 

 

 

 

 


Smoking Cessation Counseling

 

 

 

 

 

 

 


Antithrombotic Therapy at Discharge

 

 

 

 

 

 

 


Statin Therapy at Discharge

 

 

 

 

 

 

 


Anticoagulation for Atrial Fibrillation

 

 

 

 

 

 

 


Door to needle (IV tPA) time in 60 minutes

 

 

 

 

 

 

 


NIH stroke scale score recorded

 

 

 

 

 

 

 













TIA Only

 

 

Numerator*

Denominator*

Percent*

White*

Race Other*

Male*

Female*


Antithrombotic Therapy by end of Day 2

 

 

 

 

 

 

 


Stroke Education

 

 

 

 

 

 

 


Smoking Cessation Counseling

 

 

 

 

 

 

 


Antithrombotic Therapy at Discharge

 

 

 

 

 

 

 


Statin Therapy at Discharge

 

 

 

 

 

 

 


Anticoagulation for Atrial Fibrillation

 

 

 

 

 

 

 













Hemorrhagic Stroke Only

 

Numerator*

Denominator*

Percent*

White*

Race Other*

Male*

Female*


Dysphagia Screening

 

 

 

 

 

 

 


VTE Prophylaxis by end of Day 2

 

 

 

 

 

 

 


Assessed for Rehabilitation

 

 

 

 

 

 

 


Stroke Education

 

 

 

 

 

 

 


Smoking Cessation Counseling

 

 

 

 

 

 

 
























Defect free care

Numerator*

Percent*









Ischemic inpatient

 

 









Ischemic discharge

 

 









Hemorrhagic

 

 









TIA

 

 





















 










Data source: , All are weighted estimated






















Centers for Disease Control and Prevention - Division for Heart Disease and Stroke Prevention




 

 

Pre hospital performance measures (drafted 8 measures)

 

% of stroke transports with an on-scene time<15 minutes

 

% of stroke transports with a blood glucose checked and recorded

 

% of stroke transports where EMS called in a stroke alert pre-notification

 

% of stroke transports that had a stroke screen completed and recorded

 

% of stroke transports that had a documented the time last known to be well

 

% of stroke transports that had a documented time of discovery

 

% of stroke transports that had a thrombolytic stroke check completed and documented

 

% of stroke transports where EMS diagnosis agreed with hospital diagnosis

 



Post-hospital Measures (drafted 9 measures)

 

% of stroke patients discharged to home who have died by 30 days

 

% of stroke patients who were seen in ED within 30 days of discharge

 

% of stroke patients who were readmitted to the hospital within 30 days of discharge

 

% of stroke patients reporting blood pressure (BP) > 140 systolic or > 90 diastolic among those checking their BP at home

 

% of stroke patients checking the BP at home

 

% of stroke patients reporting 2 or more falls within 30 days of discharge

 

% of stroke patients who stopped taking medications since discharge

 

% of stroke transports where EMS diagnosis agreed with hospital diagnosis

 

% of stroke patients that had a follow-up appointment scheduled prior to discharge

 



Adherence to the performance measures

 

% adherence to Coverdell patient-level performance measures of care for EMS

 

% adherence to Coverdell patient-level performance measures of care for in-hospital and transition of care

 

% of patients with defect-free in-hospital care by stroke type

 

% of patients with defect-free care by EMS

 



Data source:

Centers for Disease Control and Prevention - Division for Heart Disease and Stroke Prevention




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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorChang, Tiffany (CDC/ONDIEH/NCCDPHP) (CTR)
File Modified0000-00-00
File Created2021-01-14

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