Crosswalk in-hospital changes

Attachment 11b_Crosswalk of in hospital changes_Clean.xlsx

Paul Coverdell National Acute Stroke Program (PCNASP) Reporting System

Crosswalk in-hospital changes

OMB: 0920-1108

Document [xlsx]
Download: xlsx | pdf





GREEN = REQUIRED
BLUE = OPTIONAL







Modified question Deleted question New required question New optional question
Current PCNASP In-Hospital Data Dictionary (0920-1108; exp. 9/30/2022)
Requested changes

Original Data element Original question Response options
Data element Revised question Response options Change description


1

<HlthInsM> Medicare/Medicare Advantage 1 -Yes; 0 - No/ND
<HlthInsM> Medicare/Medicare Advantage 1 -Yes; 0 - No/ND Elements changed to required as information is required for summary data and program analyses. Also TJC required.


1

<HlthInsC> Medicaid 1 -Yes; 0 - No/ND
<HlthInsC> Medicaid 1 -Yes; 0 - No/ND


1

<HlthInsP> Private/VA/Champus/Other 1 -Yes; 0 - No/ND
<HlthInsP> Private/VA/Champus/Other 1 -Yes; 0 - No/ND


1

<HlthInsN> Self Pay/No Insurance 1 -Yes; 0 - No/ND
<HlthInsN> Self Pay/No Insurance 1 -Yes; 0 - No/ND


1

<HlthInND> Not Documented 1 -Yes; 0 - No/ND
<HlthInND> Not Documented 1 -Yes; 0 - No/ND

1


<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



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<mRS_pre> Modified Rankin Score pre-stroke 1 = A pre-stroke mRS of 0, 1, or 2 was documented in the medical record, OR physician/APN/PA documentation that the patient was able to look after self without daily help prior to this acute stroke episode.
2 = A pre-stroke mRS of 3, 4, or 5 was documented in the medical record, OR physician/APN/PA documentation that the patient could NOT look after self without daily help prior to this acute stroke episode.
3 = A pre-stroke mRS was not documented, OR unable to determine (UTD) from the medical record documentation.




Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<AdmSysBP> If patient received IV thrombolytic, what was the first systolic blood pressure? Numeric #



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<AdmDiaBP> If patient received IV thrombolytic, what was the first diastolic blood pressure? Numeric #



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<AdmGluc> If patient received IV thrombolytic, what was the first blood glucose? Numeric #



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<APlAdm> Antiplatelet medication 1 -Yes; 0 - No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ACoagAdm> Anticoagulant 1 -Yes; 0 - No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<HBPAdmYN> Antihypertensive medication 1 -Yes; 0 - No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<DprADMYN> Antidepressant medication 1 -Yes; 0 - No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO


1

<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
<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 Data element changed to required since other telestroke elements removed. Elements part of list of minimum data element for new NOFO.

1


<TeleVid> Telestroke consultation performed via interactive video 1 – Yes; 0 - No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<TeleRad> Telestroke consultation performed via teleradiology 1 – Yes; 0 - No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<TelePho> Telestroke consultation performed via telephone call 1 – Yes; 0 - No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<TeleND> Telestroke consultation method not documented 1 – Yes; 0 - No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagTYN> Was brain or vascular imaging performed prior to transfer to your facility? 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagTCT> If yes, which imaging tests were performed: CT 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagTCTA> If yes, which imaging tests were performed: CTA 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagTCTP> If yes, which imaging tests were performed: CT Perfusion 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagTMRI> If yes, which imaging tests were performed: MRI 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagTMRA> If yes, which imaging tests were performed: MRA 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagTMRP> If yes, which imaging tests were performed: MR Perfusion 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagTND> If yes, which imaging tests were performed: Image type not documented 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagTD> Date 1st vessel or perfusion imaging initiated at prior hospital 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagTDND> Date 1st vessel or perfusion imaging initiated at prior hospital not documented 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagTT> Time 1st vessel or perfusion imaging initiated at prior hospital 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagTTND> Time 1st vessel or perfusion imaging initiated at prior hospital not documented 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImageDND> Date brain imaging first initiated not documented 1 – Yes; 0 – No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImageTND> Time brain imaging first initiated not documented 1 – Yes; 0 – No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO


1

<ImageVas > Was acute vascular or perfusion imaging (e.g., CTA, MRA, DSA) performed at your hospital? 1 – Yes; 0 – No/ND
<ImageVas > Was acute vascular or perfusion imaging (e.g., CTA, MRA, DSA) performed at your hospital? 1 – Yes; 0 – No/ND Element changed to required as collection is included in list of minimum data elements for new NOFO

1


<ImageCTA> If yes, type of imaging: CTA 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImageCTP> If yes, type of imaging: CT Perfusion 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImageMRA> If yes, type of imaging: MRA 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImageMRP> If yes, type of imaging: MR Perfusion 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImageDSA> If yes, type of imaging: DSA (catheter angiography) 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImageND> If yes, type of imaging: Image type not documented 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagVD> Date 1st vessel or perfusion imaging initiated at your hospital  MMDDYYYY



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagVDND> Date 1st vessel or perfusion imaging initiated at your hospital not documented 1 – Yes; 0 – No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagVT> Time 1st vessel or perfusion imaging initiated at your hospital  Time HHMM



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<ImagVTND> Time 1st vessel or perfusion imaging initiated at your hospital not documented 1 – Yes; 0 – No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LVO> Was a target lesion (large vessel occlusion) visualized? 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LVOICA> If yes, site of large vessel occlusion: ICA 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LVOIICA> If yes, site of large vessel occlusion: Intracranial ICA 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LVOCICA> If yes, site of large vessel occlusion: Cervical ICA 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LVOIOt> If yes, site of large vessel occlusion: ICA other/UTD 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LVOMCA> If yes, site of large vessel occlusion: MCA 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LVOMCAM1> If yes, site of large vessel occlusion: MCA M1 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LVOMCAM2> If yes, site of large vessel occlusion: MCA M2 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LVOMCAOt> If yes, site of large vessel occlusion: MCA Other/UTD 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LVOBasAr> If yes, site of large vessel occlusion: Basilar artery 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LVOOth> If yes, site of large vessel occlusion: Other cerebral artery branch 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LVOVerAr> If yes, site of large vessel occlusion: Vertebral artery 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LKWDNK> Last known well date not documented 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LKWTNK> Last known well time not documented 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<DiscDNK> Discovery date not documented 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<DiscTNK> Discovery time not documented 1 – Yes; 0 – No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO
1



<TrmIVM> Was IV tPA (alteplase) initiated for this patient at this hospital? 1 - Yes; 0 - No
<TrmIVM> Was IV thrombolytic initiated for this patient at this hospital? 1 - Yes; 0 - No Question prompt modified to align with GWTG
1



<TrmIVMD> What date was IV tPA (alteplase) initiated for this patient at this hospital? MMDDYYYY
<TrmIVMD> What date was IV thrombolytic initiated for this patient at this hospital? MMDDYYYY Question prompt modified to align with GWTG

1


<TrmIVMDN> IV tPA initiation date not documented 1 - Yes; 0 - No



Individual data element to capture not document not needed
1



<TrmIVMT> What time was IV tPA (alteplase) initiated for this patient at this hospital? Time HHMM
<TrmIVMT> What time was IV thrombolytic initiated for this patient at this hospital? Time HHMM Question prompt modified to align with GWTG

1


<TrmIVMTN> IV tPA initiation time not documented 1 - Yes; 0 - No



Individual data element to capture not document not needed


1





<TrmALT> Thrombolytic used: Alteplase (Class 1 evidence) 1 - Yes; 0 - No New data element to align with recent scientific updates and align with GWTG


1





<TrmALds> Alteplase, total dose: (up to 1 decimal place) New data element to align with recent scientific updates and align with GWTG


1





<TrmTNK> Thrombolytic used: Tenecteplase (Class 2b evidence) 1 - Yes; 0 - No New data element to align with recent scientific updates and align with GWTG


1





<TrmTNds> Tenecteplase, total dose: (up to 1 decimal place) New data element to align with recent scientific updates and align with GWTG


1





<TrmTNRsn> Reason for selecting tenecteplase instead of alteplase: 1 - Large Vessel Occlusion (LVO) with potential thrombectomy
2 – Mild stroke
3 - Other
New data element to align with recent scientific updates and align with GWTG


1





<TrmExtnd> If IV thrombolytic administered beyond 4.5-hour, was imaging used to identify eligibility? 1- Yes, Diffusion-FLAIR mismatch
2- Yes, Core-Perfusion mismatch
3 – None
4 - Other
New data element to align with recent scientific updates and align with GWTG


1





<TrmIVT> IV thrombolytic at an outside hospital 1 - Yes; 0 - No New data element to align with recent scientific updates and align with GWTG


1





<TrmIVTAT> If yes, select thrombolytic administered at outside hospital or Mobile Stroke Unit: 1- Alteplase
2- Tenecteplase
New data element to align with recent scientific updates and align with GWTG

1


<CathTDND> Date of IA t-PA or MER initiated not documented 1 – Yes; 0 – No



Individual data element to capture not document not needed
1



<TrmIVT> IV tPA (alteplase) at an outside hospital 1 - Yes; 0 - No
<TrmIVT> IV thrombolytic tPA (alteplase) at an outside hospital or EMS / mobile stroke unit? 1 - Yes; 0 - No Question prompt modified to align with GWTG


1





<TrmIVTAT> If yes, select thrombolytic administered at outside hospital or Mobile Stroke Unit: 1- Alteplase
2- Tenecteplase
New data element to align with recent scientific updates and align with GWTG
1



<CathTxD> Date of IA t-PA or MER initiation at this hospital MMDDYYYY
<CathTxD> Date of IA alteplase or MER initiation at this hospital MMDDYYYY Question prompt modified to align with GWTG

1


<CathTDND> Date of IA t-PA or MER initiated not documented 1 – Yes; 0 – No



Individual data element to capture not document not needed
1



<CathTxT> Time of IA t-PA or MER initiation at this hospital  Time HHMM
<CathTxT> Time of IA alteplase or MER initiation at this hospital  Time HHMM Question prompt modified to align with GWTG

1


<CathTTND> Time of IA t-PA or MER initiation not documented 1 – Yes; 0 – No



Individual data element to capture not document not needed
1



<ThrmCmp> Complication of reperfusion therapy 0 – None; 1 –symptomatic ICH within 36 hours (< 36 hours) of tPA ; 2 - life threatening, serious systemic hemorrhage within 36 hours of tPA; 3 - other serious complications; 9 – Unknown/Unable to Determine
<ThrmCmp> Complication of reperfusion therapy (Thrombolytic or MER) 0 – None; 1 –symptomatic ICH within 36 hours (< 36 hours) of tPA ; 2 - life threatening, serious systemic hemorrhage within 36 hours of tPA; 3 - other serious complications; 9 – Unknown/Unable to Determine Question prompt modified to align with GWTG

1


<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



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtCT> Symptoms suggest subarachnoid hemorrhage; CT demonstrates multi-lobar infarction (hypodensity >1/3 cerebral hemisphere) 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<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



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtNC> Care team unable to determine eligibility 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtOH> IV or IA thrombolysis/thrombectomy given at outside hospital prior to arrival 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtIL> Life expectancy < 1 year or severe co-morbid illness or CMO on admission 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtFR> Patient/family refusal 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtRI> Rapid improvement 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtSM> Stroke severity too mild 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtA> Delay in patient arrival 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtTD> In-hospital Time Delay 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtDX> Delay in stroke diagnosis 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtIV> No IV access 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtAG> Advanced age 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtS> Stroke too severe 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtOC> Other reasons 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NonTrtOT> Other reasons (text) 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<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



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NoT4_CT> Symptoms suggest subarachnoid hemorrhage; CT demonstrates multi-lobar infarction (hypodensity >1/3 cerebral hemisphere) 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<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



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NoT4_NC> Care team unable to determine eligibility 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NoT4_OH> IV or IA thrombolysis/thrombectomy at an outside hospital prior to arrival 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NoT4_ILL> Life expectancy < 1 year or severe co-morbid illness or CMO on admission 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NoT4_FR> Patient/family refusal 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NoT4_RI> Rapid improvement 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NoT4_SM> Stroke severity too mild 1 Yes; 0 No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO


1

<tPA4NC> Documented exclusions or relative exclusions (contraindications or warnings) for not initiating IV thrombolytic in the 3-4.5 hour treatment window? 1 - Yes; 0 - No
<tPA4NC> Documented exclusions or relative exclusions (contraindications or warnings) for not initiating IV thrombolytic in the 3-4.5 hour treatment window? 1 - Yes; 0 - No Data element changed to required to capture exclusions to treatment documented. This information is necessary since remaing questions with individual reasons have been removed.

1


<NonTrtA4> Delay in patient arrival 1 - Yes; 0 - No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NoT4_ED> In-hospital Time Delay 1 - Yes; 0 - No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NoT4_DX> Delay in stroke diagnosis 1 - Yes; 0 - No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NoT4_PT> No IV access 1 - Yes; 0 - No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NoT4_O> Other reasons 1 - Yes; 0 - No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<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



Data element removed to reduce burden of inhospital data collection per scope of new NOFO
1



<tPADelay> If IV tPA (alteplase) was initiated greater than 60 minutes after hospital arrival, were eligibility or medical reasons documented as the cause for delay? 1 - Yes; 0 - No
<tPADelay> If IV thrombolytic was initiated greater than 60 minutes after hospital arrival, were eligibility or medical reasons documented as the cause for delay? 1 - Yes; 0 - No Question prompt modified to align with GWTG
1



<tPADel45> If IV tPA (alteplase) was initiated greater than 45 minutes after hospital arrival, were eligibility or medical response documented as the cause for delay? 1 - Yes; 0 - No
<tPADel45> If IV thrombolytic was initiated greater than 45 minutes after hospital arrival, were eligibility or medical response documented as the cause for delay? 1 - Yes; 0 - No Question prompt modified to align with GWTG


1





<DelayRsn> Eligibility or Medical reason(s) documented as the cause for delay in thrombolytic administration: Need for additional PPE for suspected/ confirmed infectious disease 1 - Yes; 0 - No New data element to capture delays due to need for additional PPE. This refelect challenges due to COVID-19.

1


<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



Data elements removed as this information is no longer critical to program.

1


<ArtPDND> Date of skin puncture at this hospital to access arterial site selected not documented. 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<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?  Time HHMM



Data elements removed as this information is no longer critical to program.

1


<ArtPTND> Time of skin puncture at this hospital to access arterial site selected not documented. 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<MERPROC> Was a mechanical endovascular reperfusion procedure attempted during this episode of care (at this hospital)? 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<NoMERDoc> Are reasons for not performing mechanical endovascular reperfusion therapy documented? 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<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; MER performed at outside hospital; and/or allergy to contrast material 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<NoMEREx2> Reason for not performing mechanical endovascular therapy: equipment-related delay 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<NoMEREx3> Reason for not performing mechanical endovascular therapy: no endovascular specialist available 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<NoMEREx4> Reason for not performing mechanical endovascular therapy: delay in stroke diagnosis 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<NoMEREx5> Reason for not performing mechanical endovascular therapy: vascular imaging not performed 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<NoMEREx6> Reason for not performing mechanical endovascular therapy: advanced age 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<NoMEREx7> Reason for not performing mechanical endovascular therapy: other reason 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<MERType1> Reason for not performing mechanical endovascular therapy: other reason 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<MERType2> If MER treatment at this hospital, type of treatment: retrievable stent 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<MERType3> If MER treatment at this hospital, type of treatment: other mechanical clot retrieval device beside stent retrieval 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<MERType4> If MER treatment at this hospital, type of treatment: clot suction device 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<MERType5> If MER treatment at this hospital, type of treatment: intracranial angioplasty, with or without permanent stent 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<MERType6> If MER treatment at this hospital, type of treatment: cervical carotid angioplasty, with or without permanent stent 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<FPassD> If MER treatment at this hospital, type of treatment: other  MMDDYYYY



Data elements removed as this information is no longer critical to program.

1


<FPassDND> What is the date of the first pass of a clot retrieval device at this hospital? 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<FPassT> Date of the first pass of a clot retrieval device at this hospital not documented  Time HHMM



Data elements removed as this information is no longer critical to program.

1


<FPassTND> What is the time of the first pass of a clot retrieval device at this hospital? 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<MERDelay> Time of the first pass of a clot retrieval device at this hospital not documented 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<WhyMERD1> Is a cause(s) for delay in performing mechanical endovascular reperfusion therapy documented? 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<WhyMERD2> 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



Data elements removed as this information is no longer critical to program.

1


<WhyMERD3> Reasons for delay: delay in stroke diagnosis 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<WhyMERD4> Reasons for delay: in-hospital time delay 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<WhyMERD5> Reasons for delay: equipment-related delay 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<WhyMERD6> Reasons for delay: other 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<WhyMERD7> Reasons for delay: need for additional imaging 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<WhyMERD8> Reasons for delay: Need for additional PPE for suspected/confirmed infectious disease 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<TICIG> Reasons for delay: catheter lab not available 1 – Grade 0; 2 – Grade 1; 3 – Grade 2a; 4 – Grade 2b; 5 – Grade 3; 6 - ND



Data elements removed as this information is no longer critical to program.

1


<TICID> Thrombolysis in Cerebral Infarction (TICI) Post-Treatment Reperfusion Grade Date MMDDYYYY



Data elements removed as this information is no longer critical to program.

1


<TICIDND> Date a post-treatment TICI Reperfusion Grade of 2B/3 was first documented during the mechanical thrombectomy procedure? 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<TICIT> Date of post-treatment TICI reperfusion grade of 2B/3 not documented  Time HHMM



Data elements removed as this information is no longer critical to program.

1


<TICITND> Time a post-treatment TICI Reperfusion Grade of 2B/3 was first documented during the mechanical thrombectomy procedure? 1 - Yes; 0 - No



Data elements removed as this information is no longer critical to program.

1


<NIHSSPre> Time of post-treatment TICI reperfusion grade of 2B/3 not documented Numeric #



Data elements removed as this information is no longer critical to program.


1





<MedHisEC> is there history of E-Cigarette Use (Vaping)? (Use of electronic nicotine delivery system or electronic cigarettes (e-cigarettes)) 1 - Yes; 0 - No/ND Data elements added to aling with recent changes in GWTG to capture history of COVID infection.


1





<MedHisDT> Medical history of dementia? 1 - Yes; 0 - No/ND


1





<MH_EID> HX of Emerging Infectious Disease 1 - Yes; 0 - No/ND


1





<MH_COV1> SARS-COV-1 1 - Yes; 0 - No/ND


1





<MH_COV2> SARS-COV-2 (COVID-19) 1 - Yes; 0 - No/ND


1





<MH_MERS> MERS 1 - Yes; 0 - No/ND


1





<MH_OTH> Other infectious respiratory pathogen 1 - Yes; 0 - No/ND

1


<MHDRUG> Drug or alcohol abuse? 1 - Yes; 0 - No/ND



Data elements removed as this information is no longer critical to program.

1


<MHFHSTK> Family history of stroke 1 - Yes; 0 - No/ND



Data elements removed as this information is no longer critical to program.

1


<MHHRTX> Hormone replacement therapy 1 - Yes; 0 - No/ND



Data elements removed as this information is no longer critical to program.

1


<MHOBESE> Obesity 1 - Yes; 0 - No/ND



Data elements removed as this information is no longer critical to program.

1


<MHMIGRN> Migraines 1 - Yes; 0 - No/ND



Data elements removed as this information is no longer critical to program.

1


<MHRENAL> Chronic renal insufficiency (serum creatinine > 2.0)? 1 - Yes; 0 - No/ND



Data elements removed as this information is no longer critical to program.

1


<MedHisDP> Depression 1 - Yes; 0 - No/ND



Data elements removed as this information is no longer critical to program.

1


<MedHisSA> Sleep Apnea 1 - Yes; 0 - No/ND



Data elements removed as this information is no longer critical to program.

1


<MHDVT> DVT/PE 1 - Yes; 0 - No/ND



Data elements removed as this information is no longer critical to program.

1


< MHFH> Familial Hypercholesteremia 1 - Yes; 0 - No/ND



Data elements removed as this information is no longer critical to program.


1

<PneumYN> Was there documentation that the patient was treated for hospital acquired pneumonia (pneumonia not present on admission) during this admission? 1 – Yes; 0 - No or ND; 2 NC
<PneumYN> Was there documentation that the patient was treated for hospital acquired pneumonia (pneumonia not present on admission) during this admission? 1 – Yes; 0 - No or ND; 2 NC Question changed to required to more completely assess complications during hospital stay

1


<UTI> Was patient treated for a urinary tract infection (UTI) during this admission? 1 - Yes; 0 - No/ND



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<UTIFoley> If patient was treated for a UTI, did the patient have a Foley catheter during this admission? 1 - Yes, and patient had catheter in place on arrival; 2 - Yes, but only after admission; 0 - No; 9 - UTD



Data element removed to reduce burden of inhospital data collection per scope of new NOFO


1

<DVTDocYN> Did patient experience a DVT or pulmonary embolus (PE) during this admission? 1 - Yes; 0 - No/ND
<DVTDocYN> Did patient experience a DVT or pulmonary embolus (PE) during this admission? 1 - Yes; 0 - No/ND Question changed to required to more completely assess complications during hospital stay


1





<Inf_Cold> Seasonal cold 1 - Yes; 0 - No/ND New question added to capture COVID-19 infection or other infectious diseases. Stroke has been found to be a complication of COVID-19 infection


1





<Inf_Flu> Influenza 1 - Yes; 0 - No/ND New question added to capture COVID-19 infection or other infectious diseases. Stroke has been found to be a complication of COVID-19 infection


1





<Inf_BAC> Other Bacterial infection 1 - Yes; 0 - No/ND New question added to capture COVID-19 infection or other infectious diseases. Stroke has been found to be a complication of COVID-19 infection


1





<Inf_OTH> Other viral infection 1 - Yes; 0 - No/ND New question added to capture COVID-19 infection or other infectious diseases. Stroke has been found to be a complication of COVID-19 infection


1





<Inf_EmID> Emerging Infectious Disease 1 - Yes; 0 - No/ND New question added to capture COVID-19 infection or other infectious diseases. Stroke has been found to be a complication of COVID-19 infection


1





<Inf_COV1> SARS-COV-1 1 - Yes; 0 - No/ND New question added to capture COVID-19 infection or other infectious diseases. Stroke has been found to be a complication of COVID-19 infection


1





<Inf_COV2> SARS-COV-2 (COVID-19) 1 - Yes; 0 - No/ND New question added to capture COVID-19 infection or other infectious diseases. Stroke has been found to be a complication of COVID-19 infection


1





<Inf_MERS> MERS 1 - Yes; 0 - No/ND New question added to capture COVID-19 infection or other infectious diseases. Stroke has been found to be a complication of COVID-19 infection


1





<Inf_OEID> Other Emerging Infectious Disease 1 - Yes; 0 - No/ND New question added to capture COVID-19 infection or other infectious diseases. Stroke has been found to be a complication of COVID-19 infection


1





<Inf_NONE> None/ND 1 - Yes; 0 - No/ND New question added to capture COVID-19 infection or other infectious diseases. Stroke has been found to be a complication of COVID-19 infection

1


<ICD9PrDx> Principal discharge ICD-9-CM code  5 – digit, 2 decimal places



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<NIHSSICD> ICD-10-CM code for first captured NIHSS score (in the secondary/other diagnosis field) 0 – R29.700
...
75 – R29.7




Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<EtioDoc> Was stroke etiology documented in the patient medical record? 1 – Yes; 0 - No



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<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)



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<mRSDone> Was Modified Rankin Scale done at discharge? 1 - Yes; 0 - No/ND



Data element removed since information can be captured in another data element

1


<DprDCYN> Was the patient prescribed an antidepressant medication at discharge? 1 - Yes - SSRI; 2 - Yes - Other antidepressant; 0 - No/ND;



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<LipLDL> LDL |__|__|__| mg/dl Numeric ### 3-digit



Data element removed to reduce burden of inhospital data collection per scope of new NOFO

1


<CholesTx> Was a cholesterol-reducing treatment prescribed at discharge? 1 – None; 2 – None- contraindicated; 3 – Statin; 4 – Fibrate; 5 – Niacin; 6 – Absorption inhibitor; 7 – Other med; 8 – PCSK9 inhibitor



Data element removed to align with GWTG by modifying and adding the 5 data elements below


1





<LipNone > No cholesterol reducing treatment prescribed at discharge 1 - Yes; 0 - No/ND Data elements added to align with GWTG question that captures individual cholesterol reducing medications


1





<LipFibrt> Cholesterol reducing treatment prescribed - Fibrate 1 - Yes; 0 - No/ND


1





<LipNiacn> Cholesterol reducing treatment prescribed - Niacin 1 - Yes; 0 - No/ND


1





<LipAbsIn> Cholesterol reducing treatment prescribed – Absorption inhibitor 1 - Yes; 0 - No/ND


1





<LipPCSK> Cholesterol reducing treatment prescribed – PCSK9 inhibitor 1 - Yes; 0 - No/ND
9 148 42 0

















































































































































































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