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Quality Measures

Comprehensive Stroke Measures Q4 2019

Stroke MeasureGoal/DefinitionAchievement Averages
CSTK-01
NIHSS Performed for Ischemic Stroke Patients
Goal - 100% within 12hr of arrival99%
CSTK-02
(Report reflects Q1 data) Modified Rankin Score (mRS at 90 days)
Patient Call Back Completed at 90 Days After Discharge83%
CSTK-3
Severity Measurement Performed for SAH and ICH Patients
Severity Measurement Documentation (Goal 80%)100%
CSTK-3 B
Score for Intra Cerebral Hemorrhage Patients
Severity Measurement Documentation (Goal 80%)100%
CSTK-4
Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage
Treatment for Patients with Intracerebral Hemorrhage (Goal 100%)100%
CSTK-5
Hemorrhagic Transformation (overall rate)
0% (no bleeds, goal 0%)0%
CSTK-6
Nimodipine Compliance
Goal - Administer within 24hr for SAH (goal 100%)100%
CSTK-8
Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)
Patient receiving thrombectomy with full perfusion post procedure. (no goal)78.8%
CSTK-9
Door to groin
Goal 60 minutes41
CSTK-10
Favorable MRS at 90 day (Report reflects Q1 data)
Patient follow up call regarding Modified Rankin Score at 90 days post discharge. (no goal)55%
CSTK-11
Timeliness of Reperfusion
Arrival time to TICI 2B or higher (no goal)46%
CSTK-12
Timeliness of Reperfusion
Skin puncture to TICI 2B or higher (no goal)46%
Carotid Artery Stenting procedure complications(None) Patient that developed complications after a Carotid Artery Stent procedureNone
Carotid Endarterectomy procedure complications(None) Patient that developed complications after a Carotid Endarterectomy procedureNone

Stroke Measures Q4 2019

Stroke MeasureGoal/DefinitionAchievement Averages
Door to Needle Median TimeGoal - 30 minutes or less25 minutes
Door to Groin Median TimeGoal - 60 minutes or less41 minutes
STK-1
Venous Thromboembolism Prophylaxis
Goal 100%100%
STK-2
Antithrombotics on Discharge
Goal 100%100%
STK-3
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Goal 100%100%
STK-4
Thrombolytic Therapy
Goal 100%100%
STK-5
Antithrombotics by end of Day 2
Goal 100%100%
STK-6
Discharged on Statin Medication
Goal 100%100%
STK-8
Stroke Education at Discharge
Goal 100%100%
STK-10
Rehabilitation Assessment
Goal 100%100%