PCNASP Quarterly Performance Measure Results

Attachment 11_PCNASP Quarterly Performance Measure Results.docx

Paul Coverdell National Acute Stroke Program (PCNASP) Reporting System

PCNASP Quarterly Performance Measure Results

OMB: 0920-1108

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Paul Coverdell National Acute Stroke Registry Quarterly Performance Measure Results




Number of Hospitals:






Demographic

N*

Percent*

Age

 

 

18-29

 

 

30-44

 

 

45-59

 

 

60+

 

 

Race

 

 

White

 

 

Race other

 

 

Gender

 

 

Male

 

 

Female

 

 

Gender Missing

 

 


 

 




Arrival Mode

N*

Percent*

EMS

 

 

Private transportation

 

 

Transfer

 

 

ND

 

 




Type

N*

Percent*

Ischemic

 

 

ICH

 

 

SAH

 

 

TIA

 

 

Ill-Defined (SNS)

 

 

No stroke

 

 

Missing

 

 

Total

 

 




Data source:






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



 

 

 

 

 

 

 

 

 



Coverdell In-Hospital Performance Measures Numerator*

Denominator*

Percent*

HS/SNS

IS

TIA



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



IV tPA within 60 minutes of ED Arrival

 

 

 


X

 



NIHSS score recorded

 

 

 

 

X

 














Ischemic Stroke Only

 

 

Numerator*

Denominator*

Percent*

White*

Race Other*

Male*

Female*


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

 

 

 

 

 

 

 


IV tPA within 60 minutes of ED Arrival

 

 

 

 

 

 

 


NIHSS 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/DVT 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

 

 




















Median door-to-needle time










All

 










Ischemic only

 











 










*Indicated weighted estimates

 










Data source:






















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 Created2021-01-24

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