| Modified question |
Deleted question |
New required question |
New optional question |
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Item |
Variable name |
Text prompt |
Legal values |
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Item |
Variable name |
Text prompt |
Legal values |
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Change description |
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1 |
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Pre-Hospital/Emergency Medical System (EMS) Data |
InhospStk |
Did this stroke occur as in-patient? |
1 -Yes; 0 - No |
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Variable is deleted, because it can be captured through an existing variable. |
| 1 |
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Reasons not admitted |
WhyNoAdm |
Reasons that the patient was not admitted |
1 - discharged directly from ED to home or other location that is not an acute care hospital; 4 - Transferred from your ED to another acute care hosptial; 6 - died in ED; 7 - Left ED AMA; 8 - discharged from observation status without an inpatient admission; 0 - Other; |
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Reasons not admitted |
WhyNoAdm |
Reasons that the patient was not admitted |
1 - discharged directly from ED to home or other location that is not an acute care hospital; 4 - Transferred from your ED to another acute care hosptial; 6 - died in ED; 7 - Left ED AMA; 8 - discharged from observation status without an inpatient admission; 9 - Other; |
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Legal values will be modified to align with GWTG |
| 1 |
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Hospital admission data |
AmbStatA |
Was patient ambulatory prior to stroke/TIA? |
1 – Able to ambulate independently w/or w/o device; 2 - Yes but with assistance from another person; 3 - Unable to ambulate; 0 - ND |
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Hospital admission data |
AmbStatA |
Was patient ambulatory prior to stroke/TIA? |
1 – Able to ambulate independently w/or w/o device; 2 - Yes but with assistance from another person; 3 - Unable to ambulate; 9 - ND |
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Legal values will be modified to align with GWTG |
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1 |
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Functional status prior to stroke |
mRS_pre |
Modified Rankin Score pre-stroke |
0 - No symptoms; 1 - no significant disability despite symptoms; 2 - slight disability; 3 - moderate disability, can walk without assistance; 4 - moderate to severe disability, needs assistance to walk; 5 - severe disability, bedridden;9 - ND |
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This new data element was added by GWTG, which is the data collection method for a majority of Coverdell participating hospitals. Its addition aligns exactly with GWTG to reduce data burden. This question will help compare functional status before and after a stroke to improve quality of care. |
| 1 |
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Initial glucose |
AdmGlucose |
If patient received IV tPA (alteplase), what was the first blood glucose? |
Numeric # = 3 digit |
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Initial glucose |
AdmGluc |
If patient received IV tPA (alteplase), what was the first blood glucose? |
Numeric # = 3 digit |
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Variable name modified to align with GWTG |
| 1 |
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Medications currently taking prior to admission |
APltAdmYN |
Antiplatelet medication |
1 - Yes; 0 - No/ND |
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Medications currently taking prior to admission |
APlAdm |
Antiplatelet medication |
1 - Yes; 0 - No/ND |
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Variable name modified to align with GWTG |
| 1 |
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Medications currently taking prior to admission |
ACoagAdmYN |
Anticoagulant |
1 - Yes; 0 - No/ND |
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Medications currently taking prior to admission |
ACoagAdm |
Anticoagulant |
1 - Yes; 0 - No/ND |
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Variable name modified to align with GWTG |
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1 |
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Telestroke |
TeleYN |
Was telestroke consultation performed? |
1- Yes, the patient received telestroke consultation from my hospital staff when the patient was located at another hospital; 2- Yes, the patient received telestroke consultation from someone other than my staff when the patient was located at another hospital; 3- Yes, the patient received telestroke consultation from a remotely located expert when the patient was located at my hospital; 4- No telestroke consult performed; 9-ND |
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This new data element was added by GWTG. It aligns exactly with GWTG to reduce data burden. This optional question will allow CDC and states to better understand the use of telemedicine to improve stroke care. |
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1 |
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Telestroke |
TeleVid |
Telestroke consultation performed via interactive video |
1 - Yes; 0 - No |
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This new question is being added by GWTG. This optional question will allow CDC and states to better understand the use of telemedicine to improve stroke care. |
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1 |
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Telestroke |
TeleRad |
Telestroke consultation performed via teleradiology |
1 - Yes; 0 - No |
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This new question is being added by GWTG. This optional question will allow CDC and states to better understand the use of telemedicine to improve stroke care. |
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1 |
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Telestroke |
TelePho |
Telestroke consultation performed via telephone call |
1 - Yes; 0 - No |
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This new question is being added by GWTG. This optional question will allow CDC and states to better understand the use of telemedicine to improve stroke care. |
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1 |
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Imaging: prior hospital |
ImagTYN |
Was brain or vascular imaging performed prior to transfer to your facility? |
1 – Yes; 0 – No/ND |
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This optional question is added in alignment with GWTG to understand advanced stroke care |
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1 |
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Imaging: prior hospital |
ImagTCT |
If yes, which imaging tests were performed: CT |
1 – Yes; 0 – No/ND |
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This optional question is added in alignment with GWTG to understand advanced stroke care |
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1 |
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Imaging: prior hospital |
ImagTCTA |
If yes, which imaging tests were performed: CTA |
1 – Yes; 0 – No/ND |
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This optional question is added in alignment with GWTG to understand advanced stroke care |
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1 |
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Imaging: prior hospital |
ImagTCTP |
If yes, which imaging tests were performed: CT Perfusion |
1 – Yes; 0 – No/ND |
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This optional question is added in alignment with GWTG to understand advanced stroke care |
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1 |
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Imaging: prior hospital |
ImagTMRI |
If yes, which imaging tests were performed: MRI |
1 – Yes; 0 – No/ND |
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This optional question is added in alignment with GWTG to understand advanced stroke care |
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1 |
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Imaging: prior hospital |
ImagTMRA |
If yes, which imaging tests were performed: MRA |
1 – Yes; 0 – No/ND |
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This optional question is added in alignment with GWTG to understand advanced stroke care |
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1 |
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Imaging: prior hospital |
ImagTMRP |
If yes, which imaging tests were performed: MR Perfusion |
1 – Yes; 0 – No/ND |
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This optional question is added in alignment with GWTG to understand advanced stroke care |
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1 |
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Imaging: prior hospital |
ImagTDSA |
If yes, which imaging tests were performed: DSA |
1 – Yes; 0 – No/ND |
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This optional question is added in alignment with GWTG to understand advanced stroke care |
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1 |
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Imaging: prior hospital |
ImagTND |
If yes, which imaging tests were performed: Image type not documented |
1 – Yes; 0 – No/ND |
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This optional question is added in alignment with GWTG to understand advanced stroke care |
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1 |
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Imaging: prior hospital |
ImagTD |
Date 1st vessel or perfusion imaging initiated at prior hospital |
MMDDYYYY |
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This optional question is added in alignment with GWTG to understand advanced stroke care |
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1 |
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Imaging: prior hospital |
ImagTDND |
Date 1st vessel or perfusion imaging initiated at prior hospital not documented |
1 – Yes; 0 – No |
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This optional question is added in alignment with GWTG to understand advanced stroke care |
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1 |
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Imaging: prior hospital |
ImagTT |
Time 1st vessel or perfusion imaging initiated at prior hospital |
Time HHMM |
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This optional question is added in alignment with GWTG to understand advanced stroke care |
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1 |
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Imaging: prior hospital |
ImagTTND |
Time 1st vessel or perfusion imaging initiated at prior hospital not documented |
1 – Yes; 0 – No |
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This optional question is added in alignment with GWTG to understand advanced stroke care |
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1 |
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Imaging |
ImageYCT |
If brain imaging performed was it a CT? |
1- Yes; 0-No/ND |
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New question added to align with changes made by GWTG. Only required if selected "yes" to ImageYN |
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1 |
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Imaging |
ImageYMR |
If imaging perfomred was it a diffusion MRI? |
1- Yes; 0-No/ND |
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New question added to align with changes made by GWTG. Only required if selected "yes" to ImageYN |
| 1 |
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Imaging |
ImageD |
Date of brain imaging |
MMDDYYYY |
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Imaging |
ImageD |
Date brain imaging first initiated at your hospital |
MMDDYYYY |
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The modified wording of this question will align with changes made by GWTG |
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1 |
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Imaging |
ImageDND |
Date imaging first initiated not documented |
1 - Yes; 0 - No |
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This variable is added to align with GWTG |
| 1 |
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Imaging |
ImageT |
Time of brain imaging |
Time HHMM |
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Imaging |
ImageT |
Time brain imaging first initiated at your hospital |
Time HHMM |
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The modified wording of this question will align with changes made by GWTG |
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1 |
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Imaging |
ImageTND |
Date imaging first initiated not documented |
1 - Yes; 0 - No |
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This variable is added to align with GWTG |
| 1 |
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Imaging |
ImageRes |
Initial brain imaging findings? |
1- Hemorrhage; 0 - No hemorrhage; 9 - ND or not available |
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Imaging |
ImageRes |
Initial brain imaging findings? |
1- acute hemorrhage; 0 - No acute hemorrhage; 9 - ND or not available |
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Wording of legal values changed to align with GWTG |
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1 |
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Last known well |
LKWDNK |
last known well date not documented |
1 - Yes; 0 - No |
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This variable is added to align with GWTG |
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1 |
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Last known well |
LKWTNK |
Last known well time not documented |
1 - Yes; 0 - No |
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This variable is added to align with GWTG |
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1 |
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Discovery of stroke symptoms |
DiscDNK |
Discovery date not documented |
1 - Yes; 0 - No |
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This variable is added to align with GWTG |
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1 |
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Discovery of stroke symptoms |
DiscTNK |
Discovery time not documented |
1 - Yes; 0 - No |
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This variable is added to align with GWTG |
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1 |
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Thrombolytic Treatment |
TrmIVMDN |
IV tPA initiation date not documented |
1 - Yes; 0 - No |
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This variable is added to align with GWTG |
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1 |
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Thrombolytic Treatment |
TrmIVMTN |
IV tPA initiation time not documented |
1 - Yes; 0 - No |
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This variable is added to align with GWTG |
| 1 |
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Thrombolytic Treatment |
TrmIAM |
IA catheter-based reperfusion at this hospital? |
1 - Yes; 0 - No |
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Thrombolytic Treatment |
CathTx |
Catheter-based treatment at this hospital? |
1 - Yes; 0 - No |
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The modified wording and variable of this question will align with changes made by GWTG, and to capture scientific advances in stroke care |
| 1 |
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Thrombolytic Treatment |
TrmIAMD |
Date of IA catheter-based reperfusion at this hospital |
MMDDYYYY |
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Thrombolytic Treatment |
CathTxD |
Date of IA t-PA or MER initiation at this hospital |
MMDDYYYY |
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The modified wording and variable of this question will align with changes made by GWTG to provide clarity, and to capture scientific advances in stroke care |
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1 |
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Thrombolytic Treatment |
CathTDND |
Date of IA t-PA or MER initiation not documented |
1 - Yes; 0 - No |
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This variable is added to align with GWTG |
| 1 |
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Thrombolytic Treatment |
TrmIAMT |
Time of IA catheter-based reperfusion at this hospital |
Time HHMM |
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Thrombolytic Treatment |
CathTxT |
Time of IA t-PA or MER initiation at this hospital |
Time HHMM |
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The modified wording and variable of this question will align with changes made by GWTG, and to capture scientific advances in stroke care |
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1 |
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Thrombolytic Treatment |
CathTTND |
Time of IA t-PA or MER initiation not documented |
1 - Yes; 0 - No |
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This variable is added to align with GWTG |
| 1 |
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Complications of thrombolytic therapy |
ThrmCmpTX |
Were there bleeding complications in a patient transferred after IV tPA (alteplase) |
1 - yes & detected prior to transfer; 2 - yes but detected after transfer; 3 - UTD; 9 - Not applicable |
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Complications of thrombolytic therapy |
ThrmCmpt |
Were there bleeding complications in a patient transferred after IV tPA (alteplase) |
1 - yes & detected prior to transfer; 2 - yes but detected after transfer; 3 - UTD; 9 - Not applicable |
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Variable is modified to align with GTWG and adhere to character length guidelines |
| 1 |
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Reasons for no tPA - 0-3 hour window. |
NonTrtC |
Contraindications, which include any of the following: SBP > 185 or DBP > 110 mmHg Seizure at onset; Recent surgery/trauma (<15 days) Recent intracranial or spinal surgery, head trauma, or stroke (<3 mo.) History of intracranial hemorrhage or brain aneurysm or vascular malformation or brain tumor; Active internal bleeding (<22 days) Platelets <100,000, PTT> 40 sec after heparin use, or PT > 15 or INR > 1.7, or known bleeding diathesis; |
1 Yes; 0 No |
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Reasons for no tPA - 0-3 hour window. |
NonTrtC |
Contraindications, which include any of the following: Elevated blood pressure (systolic > 185 or diastolic > 110 mmHg) despite treatment; Recent intracranial or spinal surgery or significant head trauma, or prior stroke in previous 3 months; History of previous intracranial hemorrhage, intracranial neoplasm, arteriovenous malformation, or aneurysm; Active internal bleeding; Acute bleeding diathesis (low platelet count, increased PTT, INR ≥ 1.7 or use of NOAC); Arterial puncture at non-compressible site in previous 7 days; Blood glucose concentration <50 mg/dL (2.7 mmol/L) |
1 Yes; 0 No |
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Updates are needed to align with the most recent FDA-approved contraindications and warnings for thrombolytics administration. Updates will also better align with changes in GWTG |
| 1 |
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Reasons for no tPA - 0-3 hour window. |
NonTrtCT |
Suspicion of subarachnoid hemorrhage (CT findings of ICH, SAH, or major infarct signs); |
1 Yes; 0 No |
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Reasons for no tPA - 0-3 hour window. |
NonTrtCT |
Symptoms suggest subarachnoid hemorrhage; CT demonstrates multi-lobar infarction (hypodensity >1/3 cerebral hemisphere) |
1 Yes; 0 No |
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Updates are needed to align with the most recent FDA-approved contraindications and warnings for thrombolytics administration. Updates will also better align with changes in GWTG |
| 1 |
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Reasons for no tPA - 0-3 hour window. |
NonTrtWN |
Warnings: conditions that might lead to unfavorable outcomes: Stroke severity – too severe Glucose < 50 or > 400 mg/dl; left heart thrombus; increased risk of bleeding due to: acute (or recent) pericarditis, subacute bacterial endocarditis (SBE), hemostatic defects including those secondary to severe hepatic or renal disease, pregnancy, diabetic hemorrhagic retinopathy, or other hemorrhagic ophthalmic conditions , septic thrombophlebitis or occluded AV cannula at seriously infected site; patients currently receiving oral anticoagulants, e.g., Warfarin sodium; |
1 Yes; 0 No |
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Reasons for no tPA - 0-3 hour window. |
NonTrtWN |
Warnings: Pregnancy; Recent acute myocardial infarction (within previous 3 months); Seizure at onset with postictal residual neurological impairments; Major surgery or serious trauma within previous 14 days; Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days) |
1 Yes; 0 No |
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Updates are needed to align with the most recent FDA-approved contraindications and warnings for thrombolytics administration. Updates will also better align with changes in GWTG |
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1 |
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If no documented contraindications or warnings, do these factors apply in the 0-3 hour time window? |
NonTrtS |
Stroke too severe |
1 Yes; 0 No |
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This will be added to align with its new addition in GWTG |
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1 |
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If no documented contraindications or warnings, do these factors apply in the 0-3 hour time window? |
NonTrtOT |
Other reasons (text) |
1 Yes; 0 No |
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This will be added to align with its new addition in GWTG |
| 1 |
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Reasons for no tPA - 3-4.5 hour window |
NonTrtC4 |
Contraindications, which include any of the following: SBP > 185 or DBP > 110 mmHg Seizure at onset; Recent surgery/trauma (<15 days) Recent intracranial or spinal surgery, head trauma, or stroke (<3 mo.) History of intracranial hemorrhage or brain aneurysm or vascular malformation or brain tumor; Active internal bleeding (<22 days) Platelets <100,000, PTT> 40 sec after heparin use, or PT > 15 or INR > 1.7, or known bleeding diathesis; |
1 Yes; 0 No |
|
Reasons for no tPA - 3-4.5 hour window |
NonTrtC4 |
Contraindications, which include any of the following: Elevated blood pressure (systolic > 185 or diastolic > 110 mmHg) despite treatment; Recent intracranial or spinal surgery or significant head trauma, or prior stroke in previous 3 months; History of previous intracranial hemorrhage, intracranial neoplasm, arteriovenous malformation, or aneurysm; Active internal bleeding; Acute bleeding diathesis (low platelet count, increased PTT, INR ≥ 1.7 or use of NOAC); Arterial puncture at non-compressible site in previous 7 days; Blood glucose concentration <50 mg/dL (2.7 mmol/L) |
1 Yes; 0 No |
|
Updates are needed to align with the most recent FDA-approved contraindications and warnings for thrombolytics administration. Updates will also better align with changes in GWTG |
| 1 |
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Reasons for no tPA - 3-4.5 hour window |
NonTrtCT4 |
Suspicion of subarachnoid hemorrhage (CT findings of ICH, SAH, or major infarct signs); |
1 Yes; 0 No |
|
Reasons for no tPA - 3-4.5 hour window |
NoT4_CT |
Symptoms suggest subarachnoid hemorrhage; CT demonstrates multi-lobar infarction (hypodensity >1/3 cerebral hemisphere) |
1 Yes; 0 No |
|
Updates are needed to align with the most recent FDA-approved contraindications and warnings for thrombolytics administration. Variable name was also modified to adhere to character length guidelines set by GWTG. This will ultimately reduce burden for states that use a mix of GWTG and other systems. |
| 1 |
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Reasons for no tPA - 3-4.5 hour window |
NonTrtWN4 |
Warnings: conditions that might lead to unfavorable outcomes: Stroke severity – too severe Glucose < 50 or > 400 mg/dl; left heart thrombus; increased risk of bleeding due to: acute (or recent) pericarditis, subacute bacterial endocarditis (SBE), hemostatic defects including those secondary to severe hepatic or renal disease, pregnancy, diabetic hemorrhagic retinopathy, or other hemorrhagic ophthalmic conditions , septic thrombophlebitis or occluded AV cannula at seriously infected site; patients currently receiving oral anticoagulants, e.g., Warfarin sodium; |
1 Yes; 0 No |
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Reasons for no tPA - 3-4.5 hour window |
NoT4_WN |
Warnings: Pregnancy; Recent acute myocardial infarction (within previous 3 months); Seizure at onset with postictal residual neurological impairments; Major surgery or serious trauma within previous 14 days; Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days) |
1 Yes; 0 No |
|
Updates are needed to align with the most recent FDA-approved contraindications and warnings for thrombolytics administration. Variable name is also modified to adhere to character length guidelines set by GWTG. This will ultimately reduce burden for states that use a mix of GWTG and other systems. |
| 1 |
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Reasons for no tPA - 3-4.5 hour window |
NonTrtNC4 |
Care team unable to determine eligibility |
1 Yes; 0 No |
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Reasons for no tPA - 3-4.5 hour window |
NoT4_NC |
Care team unable to determine eligibility |
1 Yes; 0 No |
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Variable name is modified to adhere to character length guidelines set by GWTG. This will ultimately reduce burden for states that use a mix of GWTG and other systems. |
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1 |
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Reasons for no tPA - 3-4.5 hour window |
NoT4_OH |
IV or IA thrombolysis/thrombectomy at an outside hospital prior to arrival |
1 Yes; 0 No |
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New optional variable will be collected to capture thrombolytic administration prior to hospital arrival |
| 1 |
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Reasons for no tPA - 3-4.5 hour window |
NonTrtIL4 |
Life expectancy <1 year or severe co-morbid illness or CMO on admission |
1 Yes; 0 No |
|
Reasons for no tPA - 3-4.5 hour window |
NoT4_ILL |
Life expectancy <1 year or severe co-morbid illness or CMO on admission |
1 Yes; 0 No |
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Variable name is modified to adhere to character length guidelines set by GWTG. This will ultimately reduce burden for states that use a mix of GWTG and other systems. |
| 1 |
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Reasons for no tPA - 3-4.5 hour window |
NonTrtFR4 |
Family refusal |
1 Yes; 0 No |
|
Reasons for no tPA - 3-4.5 hour window |
NoT4_FR |
Patient/family refusal |
1 Yes; 0 No |
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Variable name is modified to adhere to character length guidelines set by GWTG. This will ultimately reduce burden for states that use a mix of GWTG and other systems. |
| 1 |
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Reasons for no tPA - 3-4.5 hour window |
NonTrtRI4 |
Rapid improvement |
1 Yes; 0 No |
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Reasons for no tPA - 3-4.5 hour window |
NoT4_RI |
Rapid improvement |
1 Yes; 0 No |
|
Variable name is modified to adhere to character length guidelines set by GWTG. This will ultimately reduce burden for states that use a mix of GWTG and other systems. |
| 1 |
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Reasons for no tPA - 3-4.5 hour window |
NonTrtSM4 |
Stroke severity too mild |
1 Yes; 0 No |
|
Reasons for no tPA - 3-4.5 hour window |
NoT4_SM |
Stroke severity too mild |
1 Yes; 0 No |
|
Variable name is modified to adhere to character length guidelines set by GWTG. This will ultimately reduce burden for states that use a mix of GWTG and other systems. |
| 1 |
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If no documented contraindicatiosn or warnings, do these factors apply in the 3-4.5 hour time window? |
NonTrtTD4 |
Inhospital time delay |
1 Yes; 0 No |
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If no documented contraindicatiosn or warnings, do these factors apply in the 3-4.5 hour time window? |
NoT4_ED |
In-hospital time delay |
1 Yes; 0 No |
|
Variable name is modified to adhere to character length guidelines set by GWTG. This will ultimately reduce burden for states that use a mix of GWTG and other systems. |
| 1 |
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If no documented contraindicatiosn or warnings, do these factors apply in the 3-4.5 hour time window? |
NonTrtDX4 |
Unable to diagnose or did not diagnose in 3 hour time frame |
1 Yes; 0 No |
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If no documented contraindicatiosn or warnings, do these factors apply in the 3-4.5 hour time window? |
NoT4_DX |
Delay in stroke diagnosis |
1 Yes; 0 No |
|
Variable name is modified to adhere to character length guidelines set by GWTG. This will ultimately reduce burden for states that use a mix of GWTG and other systems. |
| 1 |
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If no documented contraindicatiosn or warnings, do these factors apply in the 3-4.5 hour time window? |
NonTrtIV4 |
No IV access |
1 Yes; 0 No |
|
If no documented contraindicatiosn or warnings, do these factors apply in the 3-4.5 hour time window? |
NoT4_PT |
No IV access |
1 Yes; 0 No |
|
Variable name is modified to adhere to character length guidelines set by GWTG. This will ultimately reduce burden for states that use a mix of GWTG and other systems. |
| 1 |
|
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|
If no documented contraindicatiosn or warnings, do these factors apply in the 3-4.5 hour time window? |
NonTrtOC4 |
Other: |
1 Yes; 0 No |
|
If no documented contraindicatiosn or warnings, do these factors apply in the 3-4.5 hour time window? |
NoT4_O |
Other reasons |
1 Yes; 0 No |
|
Variable name is modified to adhere to character length guidelines set by GWTG. This will ultimately reduce burden for states that use a mix of GWTG and other systems. |
| 1 |
|
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|
Other warnings for patients treated in the 3-4.5 hour window? |
NonTrMCA |
Were there other documented warning conditions for patients treated in the 3-4.5 hour time window? |
1 Yes; 0 No |
|
Other warnings for patients treated in the 3-4.5 hour window? |
NonTrMCA |
Additional relative exclusion criteria: Age >80; History of both diabetes and prior ischemic stroke; Taking an oral anticoagulant regardless of INR; Severe stroke (NIHSS >25) |
1 Yes; 0 No |
|
Updates are needed to align with the most recent FDA-approved contraindications and warnings for thrombolytics administration. |
|
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1 |
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|
|
IV tPA delay |
tPADel45 |
If IV tPA (alteplase) was initiated greater than 45 minutes after hospital arrival, were eligibility or medical reasons documented as the cause for delay? |
1 Yes; 0 No |
|
New required element to align with new national time goals set by AHA/ASA. |
|
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1 |
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|
Brain imaging |
ImageVas |
Was vascular or perfusion imaging performed at your hospital? |
1 - Yes; 0 - No/ND |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
ImageCTA |
If yes, type of imaging: CTA |
1 - Yes; 0 - No/ND |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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|
Brain imaging |
ImageCTP |
If yes, type of imaging: CT Perfusion |
1 - Yes; 0 - No/ND |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
ImageMRA |
If yes, type of imaging: MRA |
1 - Yes; 0 - No/ND |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
ImageMRP |
If yes, type of imaging: MR Perfusion |
1 - Yes; 0 - No/ND |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
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1 |
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|
Brain imaging |
ImageDSA |
If yes, type of imaging: DSA (catheter angiography) |
1 - Yes; 0 - No/ND |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
ImageND |
If yes, type of imaging: ND |
1 - Yes; 0 - No/ND |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
ImagVD |
Date 1st vessel or perfusion imaging initiated at your hospital |
MMDDYYYY |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
ImagVDND |
Date 1st vessel or perfusion imaging initiated at your hospital not documented |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
ImagT |
Time 1st vessel or perfusion imaging initiated at your hospital |
Time HHMM |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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|
Brain imaging |
ImagTND |
Time 1st vessel or perfusion imaging initiated at your hospital not documented |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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|
Brain imaging |
LVO |
Was a target lesion (large vessel occlusion) visualized? |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
LVOICA |
If yes, site of large vessel occlusion: ICA |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
LVOIICA |
If yes, site of large vessel occlusion: Intracranial ICA |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
LVOCICA |
If yes, site of large vessel occlusion: Cervical ICA |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
LVOIOt |
If yes, site of large vessel occlusion: ICA other/UTD |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
LVOMCA |
If yes, site of large vessel occlusion: MCA |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
LVOMCAM1 |
If yes, site of large vessel occlusion: MCA M1 |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
LVOMCAM2 |
If yes, site of large vessel occlusion: MCA M2 |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
LVOMCAOt |
If yes, site of large vessel occlusion: MCA Other/UTD |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
LVOBasAr |
If yes, site of large vessel occlusion: Basilar artery |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
LVOOth |
If yes, site of large vessel occlusion: Other cerebral artery branch |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Brain imaging |
LVOVerAr |
If yes, site of large vessel occlusion: Vertebral artery |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Catheter-based endovascular stroke treatment |
ArtPuncD |
What is the date of skin puncture at this hospital to access the arterial site selected for endovascular treatment of a cerebral artery occlusion? |
MMDDYYYY |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Catheter-based endovascular stroke treatment |
ArtPuncT |
What is the time of skin puncture at this hospital to access the arterial site selected for endovascular treatment of a cerebral artery occlusion? |
Times HHMM |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Catheter-based endovascular stroke treatment |
MERPROC |
Was a mechanical endovascular reperfusion procedure attempted during this episode of care (at this hospital)? |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Catheter-based endovascular stroke treatment |
NoMERDoc |
Are reasons for not performing mechanical endovascular reperfusion therapy documented? |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Catheter-based endovascular stroke treatment |
NoMEREx1 |
Reasons for not performing mechanical endovascular therapy includes: significant pre-stroke disability (pre-stroke mRS >1); no evidence of proximal occlusion; NIHSS <6; brain imaging not favorable/hemorrhage transformation (ASPECTS score <6); groin puncture could not be initiated within 6 hours of symptom onset; anatomical reason- unfavorable vascular anatomy that limits access to the occluded artery; patient/family refusal; and/or MER performed at outside hospital |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Catheter-based endovascular stroke treatment |
NoMEREx2 |
Reason for not performing mechanical endovascular therapy: equipment-related delay |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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Catheter-based endovascular stroke treatment |
NoMEREx3 |
Reason for not performing mechanical endovascular therapy: no endovascular specialist available |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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|
Catheter-based endovascular stroke treatment |
NoMEREx4 |
Reason for not performing mechanical endovascular therapy: delay in stroke diagnosis |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
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1 |
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|
Catheter-based endovascular stroke treatment |
NoMEREx5 |
Reason for not performing mechanical endovascular therapy: vascular imaging not performed |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
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1 |
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|
Catheter-based endovascular stroke treatment |
NoMEREx6 |
Reason for not performing mechanical endovascular therapy: advanced age |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
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1 |
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|
Catheter-based endovascular stroke treatment |
NoMEREx7 |
Reason for not performing mechanical endovascular therapy: other reason |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
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1 |
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Catheter-based endovascular stroke treatment |
MERType1 |
If MER treatment at this hospital, type of treatment: retrievable stent |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
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1 |
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Catheter-based endovascular stroke treatment |
MERType2 |
If MER treatment at this hospital, type of treatment: other mechanic al clot removal device besides stent retrieval |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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1 |
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|
Catheter-based endovascular stroke treatment |
MERType3 |
If MER treatment at this hospital, type of treatment: clot suction device |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
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1 |
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|
Catheter-based endovascular stroke treatment |
MERType4 |
If MER treatment at this hospital, type of treatment: intracranial angioplasty, with or without permanent stent |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
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1 |
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|
Catheter-based endovascular stroke treatment |
MERType5 |
If MER treatment at this hospital, type of treatment: cervical carotid angioplasty, with or without permanent stent |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
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1 |
|
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|
Catheter-based endovascular stroke treatment |
MERType6 |
If MER treatment at this hospital, type of treatment: other mechanic al clot removal device besides stent retrieval |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
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|
1 |
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|
|
Catheter-based endovascular stroke treatment |
FPassD |
What is the date of the first pass of a clot retrieval device at this hospital? |
MMDDYYYY |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
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|
Catheter-based endovascular stroke treatment |
FPassDND |
Date of the first pass of clot retrieval device at this hospital not documented |
1 - Yes; 0 - No |
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1 |
|
|
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|
|
Catheter-based endovascular stroke treatment |
FPassT |
What is the time of the first pass of a clot retrieval device at this hospital? |
Time HHMM |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
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|
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|
|
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|
|
|
Catheter-based endovascular stroke treatment |
FPassTND |
Time of the first pass of clot retrieval device at this hospital not documented |
1 - Yes; 0 - No |
|
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|
|
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1 |
|
|
|
|
|
|
Catheter-based endovascular stroke treatment |
MERDelay |
Is a cause(s) for delay in performing mechanical endovascular reperfusion therapy documented? |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
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|
1 |
|
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|
|
Catheter-based endovascular stroke treatment |
WhyMERD1 |
Reasons for delay: social/religious; initial refusal; care-team unable to determine eligibility; management of concomitant emergent/acute conditions such as cardiopulmonary arrest, respiratory failure (requiring intubation); and/or investigational or experimental protocol for thrombolysis |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
|
|
1 |
|
|
|
|
|
|
Catheter-based endovascular stroke treatment |
WhyMERD2 |
Reasons for delay: delay in stroke diagnosis |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
|
|
1 |
|
|
|
|
|
|
Catheter-based endovascular stroke treatment |
WhyMERD3 |
Reasons for delay: in-hospital time delay |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
|
|
1 |
|
|
|
|
|
|
Catheter-based endovascular stroke treatment |
WhyMERD4 |
Reasons for delay: equipment-related delay |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
|
|
1 |
|
|
|
|
|
|
Catheter-based endovascular stroke treatment |
WhyMERD5 |
Reasons for delay: other |
1 - Yes; 0 - No |
|
Added as optional to collect information for advanced stroke treatment performance measures. Question is only available for certain stroke patients |
|
|
|
1 |
|
|
|
|
|
|
Catheter-based endovascular stroke treatment |
TICIG |
Thrombolysis in Cerebral Infarction (TICI) Post-Treatment Reperfusion Grade |
1 – Grade 0; 2 – Grade 1; 3 – Grade 2a; 4 – Grade 2b; 5 – Grade 3; 6 - ND |
|
This optional question is added to capture advanced stroke treatment |
|
|
|
1 |
|
|
|
|
|
|
Catheter-based endovascular stroke treatment |
TICID |
Date a post-treatment TICI Reperfusion Grade of 2B/3 was first documented during the mechanical thrombectomy procedure? |
Date MMDDYYYY |
|
This optional question is added to capture advanced stroke treatment |
|
|
|
|
|
|
|
|
|
|
Catheter-based endovascular stroke treatment |
TICIDND |
Date a post-treatment TICI reperfusion grade 2B/3 not documented |
1 - Yes; 0 - No |
|
|
|
|
|
1 |
|
|
|
|
|
|
Catheter-based endovascular stroke treatment |
TICIT |
Time a post-treatment TICI Reperfusion Grade of 2B/3 was first documented during the mechanical thrombectomy procedure? |
Time HHMM |
|
This optional question is added to capture advanced stroke treatment |
|
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|
|
|
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|
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|
|
Catheter-based endovascular stroke treatment |
TICITND |
Time a post-treatment TICI reperfusion grade 2B/3 not documented |
1 - Yes; 0 - No |
|
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|
|
|
1 |
|
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|
|
|
NIHSSPre |
What is the last NIHSS score documented prior to initiation of IA t-PA or MER at this hospital? |
Numeric # = 1 digit |
|
This optional question is needed for advanced stroke treatment performance measures |
| 1 |
|
|
|
|
Documented past medical history |
MedhisDrug |
Drug or alcohol abuse? |
1 - Yes; 0 - No/ND |
|
Documented past medical history |
MHDRUG |
Drug or alcohol abuse? |
1 - Yes; 0 - No/ND |
|
This variable name is modified to align with GWTG |
| 1 |
|
|
|
|
Documented past medical history |
MedhisFHStk |
Family history of stroke |
1 - Yes; 0 - No/ND |
|
Documented past medical history |
MHFHSTK |
Family history of stroke |
1 - Yes; 0 - No/ND |
|
This variable name is modified to align with GWTG |
| 1 |
|
|
|
|
Documented past medical history |
MedHisHRT |
Hormone replacement therapy |
1 - Yes; 0 - No/ND |
|
Documented past medical history |
MHHRTX |
Hormone replacement therapy |
1 - Yes; 0 - No/ND |
|
This variable name is modified to align with GWTG |
| 1 |
|
|
|
|
Documented past medical history |
MedHisObese |
Obesity |
1 - Yes; 0 - No/ND |
|
Documented past medical history |
MHOBESE |
Obesity |
1 - Yes; 0 - No/ND |
|
This variable name is modified to align with GWTG |
| 1 |
|
|
|
|
Documented past medical history |
MedHisMig |
Migraines |
1 - Yes; 0 - No/ND |
|
Documented past medical history |
MHMIGRN |
Migraines |
1 - Yes; 0 - No/ND |
|
This variable name is modified to align with GWTG |
| 1 |
|
|
|
|
Documented past medical history |
MedHisRenal |
Chronic renal insufficiency (serum creatinine > 2.0)? |
1 - Yes; 0 - No/ND |
|
Documented past medical history |
MHRENAL |
Chronic renal insufficiency (serum creatinine > 2.0)? |
1 - Yes; 0 - No/ND |
|
This variable name is modified to align with GWTG |
|
|
1 |
|
|
|
|
|
|
|
Dysphagia Screening |
Dyspha24 |
Was the patient screened for dysphagia within 24 hours of admission? |
1 – Yes; 0 - No or ND; 2 - NC |
|
Question is needed to capture this data for dysphagia screening performance measure. |
| 1 |
|
|
|
|
VTE Prophylaxis |
OFXaVTEReason |
Is there a documented reason for using Oral Factor Xa Inhibitor for VTE? |
1 - Yes; 0 - No |
|
VTE Prophylaxis |
OFXAVTE |
Is there a documented reason for using Oral Factor Xa Inhibitor for VTE? |
1 - Yes; 0 - No |
|
Variable name is modified to align with GWTG |
| 1 |
|
|
|
|
Dysphagia Screening |
DysphaPF |
If patient was screened for dysphagia, what were the results of the screen? |
1 - Pass; 2 - Fail; 9 - ND |
|
Dysphagia Screening |
DysphaPF |
If patient was screened for dysphagia, what were the results of the most recent screen prior to oral intake? |
1 - Pass; 2 - Fail; 9 - ND |
|
Question wording is changed to align with GWTG. |
|
|
|
1 |
|
|
|
|
|
|
NIHSS ICD-10-CM code |
NIHSSICD |
ICD-10-CM code for first captured NIHSS score (any position) |
0 – R29.700; 1 – R29.701; 2 – R29.702; 3 – R29.703; 4 – R29.704; 5 – R29.705; 6 – R29.706; 7 – R29.707; 8 – R29.708; 9 – R29.709; 10 – R29.710; 11 – R29.711; 12 – R29.712; 13 – R29.713; 14 – R29.714; 15 – R29.715; 16 – R29.716; 17 – R29.717; 18 – R29.718; 19 – R29.719; 20 – R29.720; 21 – R29.721; 22 – R29.722; 23 – R29.723; 24 – R29.724; 25 – R29.725; 26 – R29.726; 27 – R29.727; 28 – R29.728; 29 – R29.729; 30 – R29.730; 31 – R29.731; 32 – R29.732; 33 – R29.733; 34 – R29.734; 35 – R29.735; 36 – R29.736; 37 – R29.737; 38 – R29.738; 39 – R29.739; 40 – R29.740; 41 – R29.741; 42 – R29.742; 70 – R29.70; 71 – R29.71; 72 – R29.72; 73 – R29.73; 74 – R29.74; 75 – R29.7 |
|
Addition of this optional variable will provide an understanding of agreement between clinically documented NIHSS and those that are included as ICD-10-CM codes before stroke severity is added into nationally reported risk-adjustment models |
|
|
|
1 |
|
|
|
|
|
|
Stroke etiology |
EtioDoc |
Was stroke etiology documented in the patient medical record? |
1 – Yes; 0 - No |
|
Addition of this optional variable is needed to capture information on mechanism of the stroke documented in the patient record. It aligns directly with GWTG. |
|
|
|
1 |
|
|
|
|
|
|
Stroke etiology |
EtioType |
If the stroke etiology was documented, select the type. |
1 – Large-artery atherosclerosis (e.g., carotid or basilar stenosis); 2 – Cardioembolism (e.g., atrial fibrillation/flutter, prosthetic heart valve, recent MI); 3 – Small-vessel occlusion (e.g., subcortical or brain stem lacunar infarction <1.5 cm); 4 – Stroke of other determined etiology (e.g., dissection, hypercoagulability, other); 5 – Cryptogenic stroke (multiple potential etiologies, undetermined etiology); 9 - Unspecified |
|
Addition of this optional variable is needed to capture information on mechanism of the stroke documented in the patient record. It aligns directly with GWTG. |
|
|
1 |
|
|
|
|
|
|
|
Lipid Treatment |
CholesTx |
Was a cholesterol-reducing treatment prescribed at discharge? |
1 – None; 2 – None- contraindicated; 3 – Statin; 4 – Fibrate; 5 – Other med; 7 – Niacin; 8 – Absorption inhibitor; 9 – PCSK9 |
|
This new variable is needed for the calculation of a new intensive statin therapy perfoirmance measure. It aligns directly with GWTG, which requires the collection of this question. |
|
|
1 |
|
|
|
|
|
|
|
Lipid Treatment |
StatnDos |
Statin dose |
Text 25 characters |
|
This new variable is needed for the calculation of a new intensive statin therapy perfoirmance measure. It aligns directly with GWTG, which requires the collection of this question. |
|
|
1 |
|
|
|
|
|
|
|
Lipid Treatment |
StatnInt |
What intensity was the statin that was prescribed at discharge? |
1 - High-intensity statin; 2 - Moderate-intensity statin; 3 – Low-intensity statin; 9 - Unknown |
|
This new variable is needed for the calculation of a new intensive statin therapy perfoirmance measure. Specific medications that are collected by GWTG are mapped to the legal value categories to reduce burden. |
|
|
1 |
|
|
|
|
|
|
|
Lipid Treatment |
StatnWhy |
Was there a documented reason for not prescribing guideline recommended statin dose? |
1 - Intolerant to moderate or greater intensity; 2 - No evidence of atherosclerosis (cerebral, coronary, or peripheral vascular disease); 3 - Other documented reason; 9 - Unknown |
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This new variable is needed for the calculation of a new intensive statin therapy perfoirmance measure. It aligns directly with GWTG, which requires the collection of this question. |
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Antithrombotics at discharge |
AthDCPlts |
If patient was discharged on an antithrombotic medication, was it an antiplatelet? |
1 - Yes; 0 - No/ND |
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Antithrombotics at discharge |
DC_PLT |
If patient was discharged on an antithrombotic medication, was it an antiplatelet? |
1 - Yes; 0 - No/ND |
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Variable name is modified to align with GWTG |
| 1 |
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Antithrombotics at discharge |
AthDCCoag |
If patient was discharged on an antithrombotic medication, was it an anticoagulant? |
1 - Yes; 0 - No/ND |
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Antithrombotics at discharge |
DC_Coag |
If patient was discharged on an antithrombotic medication, was it an anticoagulant? |
1 - Yes; 0 - No/ND |
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Variable name is modified to align with GWTG |
| 38 |
1 |
20 |
74 |
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| *Variables in the table with the green background are required data elements. Variables in the table with the blue background are optional data elements. |
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