Attachment 4b_In-hospital data elements_Clean

Form Approved

OMB No. 0920-1108

Exp. Date 09/30/2022

Instructions for Paul Coverdell National Acute Stroke Program (PCNASP) In-Hospital Data Elements

Public reporting of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1108)

Demographic Data	<Age>	Age |__|__|__| years	Numeric ### = 3-digit	0 < age < 125		Required
	<Gender>	Gender	Numeric # = 1-digit	1 - Male; 2 - Female; 3 - Unknown	Select only 1 gender	Required
	<RaceW>	White	Numeric # = 1-digit	1 -Yes; 0 - No	Select all race options that apply. Default = 0	Required
	<RaceAA>	Black or African American				Required
	<RaceAs>	Asian				Required
	<RaceHPI>	Native Hawaiian or Other Pacific Islander				Required
	<RaceAIAN>	American Indian or Alaskan Native				Required
	<RaceUnk>	Unknown or unable to determine				Required
	<Hisp>	Hispanic Ethnicity		1 – Hispanic or Latino; 0 - Not Hispanic or Latino, or unknown	Hispanic ethnicity is a separate question from race	Required
	<HlthInsM>	Medicare/Medicare Advantage	Numeric # = 1-digit	1 -Yes; 0 - No	Default = 0	Required
	<HlthInsC>	Medicaid
	<HlthInsP>	Private/VA/Champus/Other
	<HlthInsN>	Self Pay/No Insurance
	<HlthInND>	Not Documented
Comfort Measures	<CMODoc>	When is the earliest time that the physician, advanced practice nurse, or PA documented that patient was on comfort measures only?	Numeric # = 1-digit	1 – Day of arrival or first day after arrival ; 2 - 2nd day after arrival or later; 3 - Timing unclear; 4 - ND/UTD		Required
Pre-Hospital/Emergency Medical System (EMS) Data	<PlcOccur>	Where was the patient when stroke was detected or when symptoms were discovered? In the case of a patient transferred to your hospital where they were an inpatient, ED patient, or NH/long-term care resident, from where was the patient transferred?	Numeric # = 1-digit	1 – Not in a healthcare setting; 2 - Another acute care facility; 3 –Chronic health care facility; 4 - Stroke occurred while patient was an inpatient in your hospital; 5 - Outpatient healthcare setting; 9 - ND or cannot be determined		Required
	<ArrMode>	How did the patient get to your hospital for treatment of their stroke?	Numeric # = 1-digit	1 – EMS from home or scene; 2 - Private transportation/taxi/other; 3 - transfer from another hospital; 10 – Mobile Stroke Unit; 9 - ND or unknown		Required
	<EMSNote>	Advance notification by EMS	Numeric # = 1-digit	1 -Yes; 0 - No/ND; 9-Not applicable		Required
Date & time of arrival at your hospital - What is the earliest documented time (military time) the patient arrived at the hospital?	<EDTriagD>	Date of arrival at your hospital	_ _ / _ _ / _ _ _ _	Date MMDDYYYY		Required
	<EDTriagT>	Time of arrival at your hospital	_ _: _ _	Time HHMM		Required
Patient Not Admitted	<NotAdmit>	Was the patient not admitted?	Numeric #=1-digit	1 - Not admitted; 0 = no, patient admitted as inpatient		Required
Reason Not Admitted
Hospital admission data	<HospadD>	Date of hospital admission	_ _ / _ _ / _ _ _ _	Date MMDDYYYY	Admit date	Required
	<AmbStatA>	Was patient ambulatory prior to the current stroke/TIA?	Numeric # = 1-digit	1 – Able to ambulate independently w/or w/o device; 2 - Yes but with assistance from another person; 3 - Unable to ambulate; 9 - ND		Required
	<sxresolv>	Did symptoms completely resolve prior to presentation?	Numeric # = 1-digit	1 - Yes; 0 - No; 9 - ND		Required
Medications currently taking prior to admission	<LipAdmYN>	Statin or other cholesterol reducer	Numeric # = 1-digit	1 -Yes; 0 - No/ND		Required
Telestroke	<TeleYN>	Was telestroke consultation performed?	Numeric # = 1-digit	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		Required
Imaging	<ImageYN>	Was Brain Imaging performed at your hospital after arrival as part of the initial evaluation for this episode of care or this event?	Numeric # = 1-digit	1 - Yes; 0 - No/ND; 9-NC		Required
	<ImageYCT>	If brain imaging performed, was it a CT scan?	Numeric # = 1-digit	1 - Yes; 0 - No/ND	Only if “Yes” to ImagYN	Required
	<ImageYMR>	If brain imaging performed, was it a MRI?	Numeric # = 1-digit	1 - Yes; 0 - No/ND	Only if “Yes” to ImagYN	Required
	<ImageD>	Date brain imaging first initiated at your hospital	_ _/ _ _/ _ _ _ _	MMDDYYYY	Only if “Yes” to ImagYN	Required
	<ImageT>	Time brain imaging first initiated at your hospital	_ _: _ _	Time HHMM	Only if “Yes” to ImagYN	Required
	<ImageRes>	Initial brain imaging findings?	Numeric # = 1-digit	1 – Acute hemorrhage; 0 - No acute hemorrhage; 9 - ND or not available	Only if “Yes” to ImagYN	Required
Brain imaging (all optional; for hospitals interested in collecting mechanical endovascular therapy measures)	<ImageVas>	Was acute vascular or perfusion imaging (e.g., CTA, MRA, DSA) performed at your hospital?	Numeric # = 1-digit	1 – Yes; 0 – No/ND	“Acute” defined as imaging performed during the acute evaluation	Required
When was the patient last known to be well (i.e., in their usual state of health or at their baseline), prior to the beginning of the current stroke or stroke-like symptoms? (To within 15 minutes of exact time is acceptable.)	<LKWD>	What date was the patient last known to be well	_ _/ _ _/ _ _ _ _	Date MMDDYYYY		Required
	<LKWT>	What time was the patient last known to be well	___: ____	Time HHMM		Required
When was the patient first discovered to have the current stroke or stroke-like symptoms? (To within 15 minutes of exact time of discovery is acceptable.)	<DiscD>	What date was the patient first discovered to have the current stroke or stroke-like symptoms?	_ _/ _ _/ _ _ _ _	Date MMDDYYYY		Required
	<DiscT>	What time was the patient first discovered to have the current stroke or stroke-like symptoms?	___: ____	Time HHMM		Required
NIH Stroke Scale Score	<NIHSSYN>	Was NIH Stroke Scale score performed as part of the initial evaluation of the patient?	Numeric # = 1-digit	1 – Yes; 0 – No/ND		Required
	<NIHStrkS>	If performed, what is the first NIH Stroke Scale total score recorded by hospital personnel?	Numeric ## = 2-digit	Range 00-42		Required
Thrombolytic Treatment	<TrmIVM>	Was IV thrombolytic initiated for this patient at this hospital?	Numeric # = 1-digit	1 - Yes; 0 - No		Required
	<TrmIVMD>	What date was IV thrombolytic initiated for this patient at this hospital?	_ _/ _ _/ _ _ _ _	MMDDYYYY	If IV thrombolytic (alteplase) was initiated at this hospital or ED, please complete this section:	Required
	<TrmIVMT>	What time was IV thrombolytic initiated for this patient at this hospital?	___: ____	Time HHMM		Required
	<TrmALT>	Thrombolytic used: Alteplase (Class 1 evidence)		1 - Yes; 0 - No		Required
	<TrmALds>	Alteplase, total dose:	Numeric #	--.- (up to 1 decimal place)	(mg)	Required
	<TrmTNK>	Thrombolytic used: Tenecteplase (Class 2b evidence)		1 - Yes; 0 - No		Required
	<TrmTNds>	Tenecteplase, total dose:	Numeric #	--.- (up to 1 decimal place)	(mg)	Required
	<TrmTNRsn>	Reason for selecting tenecteplase instead of alteplase:		1 - Large Vessel Occlusion (LVO) with potential thrombectomy 2 – Mild stroke 3 - Other		Required
	<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		Required
	<TrmIVT>	IV thrombolytic at an outside hospital or EMS / mobile stroke unit?	Numeric # = 1-digit	1 - Yes; 0 - No		Required
	<TrmIVTAT>	If yes, select thrombolytic administered at outside hospital or Mobile Stroke Unit:		1- Alteplase 2- Tenecteplase		Required
	<CathTx>	Catheter-based treatment at this hospital?	Numeric # = 1-digit	1 - Yes; 0 - No		Required
	<CathTxD>	Date of IA alteplaseor MER initiation at this hospital	_ _/ _ _/ _ _ _ _	MMDDYYYY		Required
	<CathTxT>	Time of IA alteplase or MER initiation at this hospital	___: ____	Time HHMM		Required
Complications of thrombolytic therapy	<ThrmCmp>	Complication of reperfusion therapy (Thrombolytic or MER)	Numeric # = 1-digit	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		Required
	<ThrmCmpt>	Were there bleeding complications in a patient transferred after IV tPA (alteplase)	Numeric # = 1-digit	1 - yes & detected prior to transfer; 2 - yes but detected after transfer; 3 - UTD; 9 - Not applicable		Required
Reasons for no tPA - 0-3 hour window. Were one or more of the following contraindication or warning for not administering IV thrombolytic therapy at this hospital explicitly documented by a physician, advanced practice nurse, or physician assistant’s notes in the chart?	<tPANC>	Documented exclusions or relative exclusions (contraindications or warnings) for not initiating IV thrombolytic in the 0-3 hour treatment window?	Numeric # = 1-digit	1 - Yes; 0 - No		Required
If no documented contraindications or warnings, do these factors apply in the 0-3 hour time window?	<tPA4NC>	Documented exclusions or relative exclusions (contraindications or warnings) for not initiating IV thrombolytic in the 3-4.5 hour treatment window?	Numeric # = 1-digit	1 - Yes; 0 - No		Required
IV tPA delay	<tPADelay>	If IV thrombolytic was initiated greater than 60 minutes after hospital arrival, were eligibility or medical reasons documented as the cause for delay?	Numeric # = 1-digit	1 - Yes; 0 - No		Required
	<tPADel45>	If IV thrombolytic was initiated greater than 45 minutes after hospital arrival, were eligibility or medical response documented as the cause for delay?	Numeric # = 1-digit	1 - Yes; 0 - No		Required
	<DelayRsn>	Eligibility or Medical reason(s) documented as the cause for delay in thrombolytic administration: Need for additional PPE for suspected/ confirmed infectious disease	Numeric # = 1-digit	1 - Yes; 0 - No		Required
Documented past medical history of any of the following: (check all that apply)	<MedHisDM>	Is there a history of Diabetes Mellitus (DM)?	Numeric # = 1-digit	1 - Yes; 0 - No/ND	Default = 0	Required
	<MedHisST>	Is there a history of prior Stroke?				Required
	<MedHisTI>	Is there a history of TIA/Transient ischemic attack/VBI?				Required
	<MedHisCS>	Is there a history of carotid stenosis?				Required
	<MedHisMI>	Is there a history of myocardial infarction (MI) or coronary artery disease (CAD)?				Required
	<MedHisPA>	Is there a history of peripheral arterial disease (PAD)?				Required
	<MedHisVP>	Does the patient have a valve prosthesis (heart valve)?				Required
	<MedHisHF>	Is there a history of Heart Failure (CHF)?				Required
	<MedHisSS>	Does the patient have a history of sickle cell disease (sickle cell anemia)?				Required
	<MedHisPG>	Did this event occur during pregnancy or within 6 weeks after a delivery or termination of pregnancy?				Required
	<MedHisAF>	Is there documentation in the patient’s medical history of atrial fibrillation/flutter?				Required
	<MedHisSM>	Is there documented past medical history of Smoking ( at least one cigarette during the year prior to hospital arrival?)				Required
	<MedHisEC>	Is there history of E-Cigarette Use (Vaping)? (Use of electronic nicotine delivery system or electronic cigarettes (e-cigarettes))				Required
	<Med HisDL>	Is there a medical history of Dyslipidemia?				Required
	<MedHisHT>	Is there a documented past medical history of hypertension?				Required
	<MedHisDT>	Medical history of dementia?				Required
	<MH_EID>	HX of Emerging Infectious Disease		1 - Yes; 0 - No/ND		Required
	<MH_COV1>	SARS-COV-1		1 - Yes; 0 - No/ND		Required
	<MH_COV2>	SARS-COV-2 (COVID-19)		1 - Yes; 0 - No/ND		Required
	<MH_MERS>	MERS		1 - Yes; 0 - No/ND		Required
	<MH_OTH>	Other infectious respiratory pathogen		1 - Yes; 0 - No/ND		Required
Early Antithrombotics	<AThr2Day>	Was antithrombotic therapy received by the end of hospital day 2?	Numeric # 1-digit	1 - Yes; 0 - No; 2 - NC		Required
Dysphagia Screening	<NPO>	Was the patient NPO throughout the entire hospital stay? (That is, this patient never received food, fluids, or medication by mouth at any time. This includes any medications delivered in the Emergency Room phase of care.)	Numeric # 1-digit	1 – Yes; 0 - No or ND		Required
	<DysphaYN>	Was patient screened for dysphagia prior to any oral intake, including food, fluids or medications?		1 – Yes; 0 - No or ND; 2 - NC - a documented reason for not screening exists in the medical record		Required
	<DysphaPF>	If patient was screened for dysphagia, what were the results of the most recent screen prior to oral intake?	Numeric #1-digit	1 - Pass; 2 - Fail; 9 - ND		Required
Other In-Hospital Complications	<PneumYN>	Was there documentation that the patient was treated for hospital acquired pneumonia (pneumonia not present on admission) during this admission?	Numeric # 1-digit	1 – Yes; 0 - No or ND; 2 NC		Required
VTE Prophylaxis	<VTELDUH>	Low dose unfractionated heparin (LDUH)	Numeric #1-digit	1 - Yes; 0 - No	Select all therapies given	Required
	<VTELMWH>	Low molecular weight heparin (LMWH)
	<VTEIPC>	Intermittent pneumatic compression devices
	<VTEGCS>	Graduated compression stockings (GCS)
	<VTEXaI>	Factor Xa Inhibitor
	<VTEWar>	Warfarin
	<VTEVFP>	Venous foot pumps
	<VTEOXaI>	Oral Factor Xa Inhibitor
	<VTEAsprn>	Aspirin
	<VTEND>	Not Documented or none of the above
	<VTEDate>	What date was the initial VTE prophylaxis administered?	__/__/____	Date MMDDYYYY		Required
	<NoVTEDoc>	If not documented or none of the above types of prophylaxis apply, is there documentation why prophylaxis was not administered at hospital admission?	Numeric #1-digit	1 - Yes; 0 - No		Required
	<OFXAVTE>	Is there a documented reason for using Oral Factor Xa Inhibitor for VTE?	Numeric #1-digit	1 - Yes; 0 - No	New January 2013 for TJC	Required
Other Therapeutic Anticoagulation	<LDUHIV>	Unfractionated heparin IV	Numeric #1-digit	1 - Yes; 0 - No		Required
	<Dabigat>	Dabigatran (Pradaxa)
	<Argatro>	Argatroban
	<Desirud>	Desirudin (Iprivask)
	<OralXaI>	Oral Factor Xa Inhibitors (e.g., rivaroxaban/Xarelto)
	<Lepirud>	Lepirudin (Refludan)
	<OthACoag>	Other Anticoagulant
Other complications	<DVTDocYN>	Did patient experience a DVT or pulmonary embolus (PE) during this admission?	Numeric # 1-digit	1 - Yes; 0 - No/ND		Required
Active bacterial or viral infection at admission or during hospitalization:	<Inf_Cold>	Seasonal cold or flu	Numeric # 1-digit	1 - Yes; 0 - No		Required
	<Inf_Flu>	Influenza		1 - Yes; 0 - No		Required
	<Inf_BAC>	Bacterial infection		1 - Yes; 0 - No		Required
	<Inf_OTH>	Other viral infection		1 - Yes; 0 - No		Required
	<Inf_EmID>	Emerging Infectious Disease		1 - Yes; 0 - No		Required
	<Inf_COV1>	SARS-COV-1		1 - Yes; 0 - No		Required
	<Inf_COV2>	SARS-COV-2 (COVID-19)		1 - Yes; 0 - No		Required
	<Inf_MERS>	MERS		1 - Yes; 0 - No		Required
	<Inf_OEID>	Other Emerging Infectious Disease		1 - Yes; 0 - No		Required
	<Inf_NONE>	None/ND		1 - Yes; 0 - No		Required
Date of discharge from hospital	<DschrgD>	What date was the patient discharged from hospital?	_ _/ _ _/_ _ _ _	Date MMDDYYYY		Required
Principal discharge ICD-10-CM diagnosis	<ICD10Dx>	Principal discharge ICD-10-CM code	_ _ _ . _ _ _ _	alphanumeric, 3 before decimal, 4 after decimal		Required
Clinical diagnosis related to stroke that was ultimately responsible for this admission (check only one item)	<AdmDxSH>	Subarachnoid hemorrhage	Numeric ## 1-digit	1 - Yes; 0 - No		Required
	<AdmDxIH>	Intracerebral hemorrhage
	<AdmDxIS>	Ischemic stroke
	<AdmDxTIA>	Transient ischemic attack
	<AdmDxSNS>	Stroke not otherwise specified
	<AdmDxNoS>	No stroke related diagnosis
	<AdmCE>	Was patient admitted for the sole purpose of performance of a carotid intervention?	Numeric # = 1-digit	1 - Yes; 0 - No or UTD		Required
	<ClnTrial>	Was the patient enrolled in a stroke clinical trial?				Required
Discharge disposition	<DschDisp>	Discharge disposition (Check only one.)	Numeric ## 1-digit	1- Discharged to home or self care (routine discharge), with or without home health, discharged to jail or law enforcement, or to assisted living facility; 2- Discharged to home hospice; 3- Discharged to hospice in a health care facility; 4- Discharged to an acute care facility (includes critical access hospitals, cancer and children's hospitals, VA, and DOD hospitals; 5 -Discharged to another healthcare facility; 6 -Expired; 7- Left against medical advice or discontinued care; 8- Not documented or unable to determine		Required
	<OHFType>	If discharged to another healthcare facility above (option 5), type of facility was it?	Numeric # = 1-digit	1 – Skilled nursing facility; 2 – Inpatient rehabilitation; 3 – Long-term care facility or, hospital; 4 - Intermediate care facility; 5 - Other		Required
Functional status at discharge	<mRSScore>	Modified Rankin Scale Score	Numeric # 1-digit	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; 6-death		Required
	<AmbStatD>	Ambulatory status at discharge		1 – Able to ambulate independently w/or w/o device; 2 - with assistance from another person; 3 - unable to ambulate; 9 - not documented		Required
Antihypertensive treatment at discharge	<HBPTreat>	Is there documentation that antihypertensive medication was prescribed at discharge?	Numeric # 1-digit	1 - Yes; 0 - No/ND; 2 - NC	Antihypertensive medications include ACE inhibitors, ARBs, beta-blockers, calcium channel blockers, diuretics, and others	Required
Lipid Treatment	<LipNone>	No cholesterol reducing treatment prescribed at discharge	Numeric # 1-digit	1 - Yes; 0 - No/ND		Required
	<LipStatn>	Was a statin medication prescribed at discharge?	Numeric # 1-digit	1 - Yes; 0 - No/ND		Required
	<LipOthNC>	If other lipid lowering medications not prescribed, was there a documented contraindication to other lipid lowering medication?	Numeric # 1-digit	1 - Yes; 0 - No/ND		Required
	<LipFibrt>	Cholesterol reducing treatment prescribed - Fibrate	Numeric # 1-digit	1 - Yes; 0 - No/ND		Required
	<LipOthRx>	Other cholesterol reducing medication	Numeric # 1-digit	1 - Yes; 0 - No/ND		Required
	<LipNiacn>	Cholesterol reducing treatment prescribed - Niacin	Numeric # 1-digit	1 - Yes; 0 - No/ND		Required
	<LipAbsIn>	Cholesterol reducing treatment prescribed – Absorption inhibitor	Numeric # 1-digit	1 - Yes; 0 - No/ND		Required
	<LipPCSK>	Cholesterol reducing treatment prescribed – PCSK9 inhibitor	Numeric # 1-digit	1 - Yes; 0 - No/ND		Required
	<StatnNC>	If statin not prescribed, was there a documented contraindication to statins?	Numeric # 1-digit	1 - Yes; 0 - No/ND		Required
	<StatnInt>	What intensity was the statin that was prescribed at discharge?	Numeric # 1-digit	1 - High-intensity statin; 2 - Moderate-intensity statin; 3 – Low-intensity statin; 9 - Unknown		Required
	<StatnWhy>	Was there a documented reason for not prescribing guideline recommended statin dose?	Numeric # 1-digit	1 - Intolerant to moderate (>75 years) or high (<=75 years) intensity statin; 2 - No evidence of atherosclerosis (cerebral, coronary, or peripheral vascular disease); 3 - Other documented reason; 9 - Unknown		Required
	<AFibYN>	Was atrial fibrillation/flutter or paroxysmal atrial fibrillation (PAF), documented during this episode of care?	Numeric # 1-digit	1 - Yes; 0 - No/ND		Required
Atrial Fibrillation	<AFibRx>	If a history of atrial fibrillation/flutter or PAF is documented in the medical history or if the patient experienced atrial fibrillation/flutter or PAF during this episode of care, was patient prescribed anticoagulation medication upon discharge?	Numeric # 1-digit	1 - Yes; 0 - No/ND; 2 - NC		Required
	<AthDscYN>	Was antithrombotic (antiplatelet or anticoagulant) medication prescribed at discharge?	Numeric # = 1-digit	1 - Yes; 0 - No/ND; 2 - NC		Required
Antithrombotics at Discharge	<DC_PLT>	If patient was discharged on an antithrombotic medication, was it an antiplatelet?	Numeric # = 1-digit	1 - Yes; 0 - No/ND	antiplatelet medications include aspirin, aspirin/dipyridamol, clopidogrel, ticlopidine, others	Required
	<DC_Coag>	If patient was discharged on an antithrombotic medication, was it an anticoagulant?	Numeric # = 1-digit	1 - Yes; 0 - No/ND 1 – Yes; 0 - No or not documented in the medical record; 2 - NC a documented reason exists for not performing counseling	anticoagulant medications include heparin IV, full dose LMW heparin, warfarin, dabigatran, argatroban, desirudin, fondaparinux, rivaroxaban, lipirudin, others	Required
	<SmkCesYN>	If past medical history of smoking is checked as yes, was the adult patient or their care giver given smoking cessation advice or counseling during the hospital stay?	Numeric # 1-digit			Required
Smoking Counseling	<EducRF>	Risk factors for stroke	Numeric # 1-digit	1 - Yes; 0 - No/ND		Required
Stroke Education	<EducSSx>	Stroke Warning Signs and Symptoms	Numeric # 1-digit	1 - Yes; 0 - No/ND		Required
	<EducEMS>	How to activate EMS for stroke
	<EducCC>	Need for follow-up after discharge
	<EducMeds>	Medications prescribed at discharge
Rehabilitation	<RehaPlan>	Is there documentation in the record that the patient was assessed for or received rehabilitation services?	Numeric # 1-digit	1 - Yes; 0 - No		Required