Mnstrokeregistry.net

GWTG Stroke PMT (Standard and Coverdell) Crosswalk with MSRT
PMT Data Element Name
MSRT Data Element Name
Final clinical diagnosis related to stroke Final hospital diagnosis related to stroke that was ultimately responsible for this admission When is the earliest documentation of comfort measures only? When is the earliest documented time that patient was on CMO? ARRIVAL AND ADMISSION INFORMATION
During this hospital stay, was the patient enrolled in a clinical trial in which patients Was this patient in a stroke-related clinical trial? with the same condition as the measure set were being studied? Was this patient admitted for the sole purpose of performance of elective carotid Elective Carotid intervention the sole purpose for admission? Patient location when stroke symptoms discovered Was the patient an ED patient at the facility? Where patient first received care at your hospital If not admitted to this hospital, where was patient transferred/ released? Where was the patient cared for and by whom? Admission type Where was the patient cared for and by whom? Stroke Consult Consult type (Where patient care occurred) Where was the patient cared for and by whom? Unit Location DEMOGRAPHICS
MEDICAL HISTORY
Currently pregnant or within 6 weeks postpartum Currently pregnant or within 6 weeks postpartum X=Needs to be bolded in the CRJC=Only in Joint Commission Overlay#=Outcome needs to add to Coverdell Overlay Effective for discharges 10/1/10 and later @=Abstract for cases discharged prior to 10/1/10 GWTG Stroke PMT (Standard and Coverdell) Crosswalk with MSRT
PMT Data Element Name
MSRT Data Element Name
Documented past medical history of smoking (patient smoked at least one cigarette during the prior year)? Ambulatory status prior to current event? Ambulation status prior to the current event DIAGNOSIS & EVALUATION
Symptom duration if diagnosis of transient ischemic attack (<24 hours) Weakness or paresis (Initial Exam Findings) Initial exam findings: Altered level of consciousness Level of consciousness (Initial Exam Findings) Had stroke symptoms resolved at time of presentation? Stroke symptoms resolve prior to presentation? If Yes (NIHSS) - Actual, Estimated, or ND First Glasgow Coma Scale (GCS) in ICH patients MEDICATIONS PRIOR TO ADMISSION
Antithrombotic medications (antiplatelet or anticoagulant) Antithrombotic medications (antiplatelet or anticoagulant) prior toadmission Cholesterol reducing/ controlling medication SYMPTOM TIMELINE
Time of Discovery same as Last Known Well BRAIN IMAGING
Brain imaging completed at your hospital for this episode of care? Was brain imaging performed at your hospital after arrival as part of the initial evaluation for this episode of care or this event? Interpretation of first brain image after symptom onset, done at any facility IV THROMBOLYTIC THERAPY
X=Needs to be bolded in the CRJC=Only in Joint Commission Overlay#=Outcome needs to add to Coverdell Overlay Effective for discharges 10/1/10 and later @=Abstract for cases discharged prior to 10/1/10 GWTG Stroke PMT (Standard and Coverdell) Crosswalk with MSRT
PMT Data Element Name
MSRT Data Element Name
Documented contraindications or warnings for not initiating IV thrombolytic in the 0- Documented contraindications or warnings for not initiating IV thrombolytic in the 3- Unable to diagnose or did not diagnose in 3 hour time frame WAS OTHER THROMBOLYTIC/REPERFUSION THERAPY ADMINISTERED?
Was IV-tPA initiated at an outside hospital? IA catheter-based reperfusion at this hospital? Was IA catheter based reperfusion initiated at this hospital? IA catheter-based reperfusion at outside hospital? Was IA catheter based reperfusion initiated at outside hospital? Investigational or experimental protocol for thrombolysis? Investigational or experimental protocol for thrombolysis Specify the investigational or experimental protocol for thrombolysis IN-HOSPITAL TREATMENT AND COMPLICATIONS
Symptomatic intracranial hemorrhage within 36 hours of tPA Symptomatic intracranial hemorrhage within 36 hours of tPA Life-threatening, serious systemic hemorrhage within 36 hours of tPA Life-threatening, serious systemic hemorrhage within 36 hours of tPA If bleeding complications occur in patient transferred after IV-tPA Patient NPO throughout the entire hospital stay? No oral intake of medications, fluids, food throughout the entire hospital stay Was patient screened for dysphagia prior to any oral intake including water or Was patient screened for dysphagia prior to any oral intake, Treatment for Hospital- Acquired Pneumonia Was there documentation that the patient was treated for hospital acquired pneumonia (pneumonia not present on admission) during this admission? Was patient ambulating at the end of hospital day 2? Was patient ambulating the day of admission or the day after admission? X=Needs to be bolded in the CRJC=Only in Joint Commission Overlay#=Outcome needs to add to Coverdell Overlay Effective for discharges 10/1/10 and later @=Abstract for cases discharged prior to 10/1/10 GWTG Stroke PMT (Standard and Coverdell) Crosswalk with MSRT
PMT Data Element Name
MSRT Data Element Name
Was DVT prophylaxis initiated by the end of hospital day 2? Is there documentation why prophylaxis was not administered at hospital Intermittent pneumatic compression devices (IPC) Was graduated compression stockings provided to the patient? What date was the initial VTE prophylaxis administered? What date was the initial VTE prophylaxis administered? Did patient experience a DVT or pulmonary embolus (PE) duringthe admission? Was antithrombotic therapy administered by the end of hospital day 2? Is there documentation by a physician/advanced practice nurse/physician assistant or pharmacist in the medical record of a reason for not administering antithrombotic therapy by end of hospital day 2? Was patient treated for a urinary tract infection (UTI) during this admission? Was the patient treated for a urinary tract infection (UTI) during this admission? If patient was treated for a UTI, did the patient have a Foley catheter during this If patient was treated for a UTI, did the patient have a Foley MEASUREMENTS
X=Needs to be bolded in the CRJC=Only in Joint Commission Overlay#=Outcome needs to add to Coverdell Overlay Effective for discharges 10/1/10 and later @=Abstract for cases discharged prior to 10/1/10 GWTG Stroke PMT (Standard and Coverdell) Crosswalk with MSRT
PMT Data Element Name
MSRT Data Element Name
DISCHARGE INFORMATION
GWTG Ischemic Stroke-Only Estimated Mortality Rate GWTG Global Stroke Estimated Mortaility Rate Discharge Blood Pressure (Measurement closest to discharge) DISCHARGE DIAGNOSIS
ICD-9-CM Discharge Diagnosis related to stroke ICD-9 discharge diagnosis related to stroke No Stroke or TIA Related ICD-9 Code Present DISCHARGE TREATMENTS
Antithrombotic medication prescribed at hospital discharge Full dose LMW heparin (Enoxaparin, Others) If no, documented reasons for no antithrombotic therapy at discharge Documented reason for not prescribing antithrombotic medication at discharge Persistent or Paroxysmal Atrial Fibrillation/Flutter Atrial or paroxysmal fibrillation/flutter during this admission? If atrial fib/flutter or history of PAF documented, was patient discharged on Anticoagulation medication prescribed at hospital discharge? If NC, documented reasons for no anticoagulation Documented reason for not prescribing anticoagulation therapy at discharge Antihypertensive medication prescribed at hospital discharge Cholesterol reducing/controlling treatment Documented reason for not prescribing a statin medication at discharge? Documented reason for not prescribing statins at discharge Documentation that the patient has evidence of atherosclerosis? Patient/Caregiver was given smoking cessation advice or counseling during the hospital stay X=Needs to be bolded in the CRJC=Only in Joint Commission Overlay#=Outcome needs to add to Coverdell Overlay Effective for discharges 10/1/10 and later @=Abstract for cases discharged prior to 10/1/10 GWTG Stroke PMT (Standard and Coverdell) Crosswalk with MSRT
PMT Data Element Name
MSRT Data Element Name
OTHER LIFESTYLE INTERVENTIONS
Reducing weight and/or increasing activity recommendations STROKE EDUCATION
Personable Modifiable Risk Factors for Stroke STROKE REHABILITATION
Patient was assessed for and/ or received rehabilitation services? Patient received rehabilitation services during hospitalization Patient received rehab services during hospitalization Patient transferred to rehabilitation facility Patient referred to rehabilitation services following discharge Patient ineligible to receive rehabilitation services because symptoms resolved Patient ineligible to receive rehab services Patient ineligible to receive rehabilitation services due to impairment (i.e., poor Patient ineligible to receive rehab services prognosis, patient unable to tolerate rehabilitation therapeutic regimen) OPTIONAL FIELDS
PMT used concurrently or retrospectively or combination? Was a stroke admission order set used in this patient? Was a stroke discharge checklist used in this patient? ARRIVAL INFORMATION
What is the patient's source of payment for this episode of care? X=Needs to be bolded in the CRJC=Only in Joint Commission Overlay#=Outcome needs to add to Coverdell Overlay Effective for discharges 10/1/10 and later @=Abstract for cases discharged prior to 10/1/10 GWTG Stroke PMT (Standard and Coverdell) Crosswalk with MSRT
PMT Data Element Name
MSRT Data Element Name
PSC OPTIONAL FIELDS
Date/Time neurosurgical services consulted CODING KEY VARIABLES
IV THROMBOLYTIC THERAPY
Contrandications
SBP > 185 or DBP > 110 mmHg despite treatment Recent intracranial or spinal surgery, head trauma, or stroke (<3 mo.) History of intracranial hemorrhage or brain aneurysm or vascular malformation or Platelets <100,000, PTT> 40 sec after heparin use, or PT > 15 or INR > 1.7, or Warnings
Care-team unable to determine eligibility X=Needs to be bolded in the CRJC=Only in Joint Commission Overlay#=Outcome needs to add to Coverdell Overlay Effective for discharges 10/1/10 and later @=Abstract for cases discharged prior to 10/1/10 GWTG Stroke PMT (Standard and Coverdell) Crosswalk with MSRT
PMT Data Element Name
MSRT Data Element Name
Increased risk of bleeding due to comorbid conditions Life expectancy < 1 year or severe co-morbid illness or CMO on admission Additional Warnings
Prior stroke and presence or history of diabetes Any anticoagulant use prior to admission (even if INR < 1.7) CT findings of stroke involving more than 1/3 of middle carotid artery MSRT ONLY FIELDS
Was patient placed on observation status or in an observation unit at this hospital? If not admitted to this hospital, where was patient transferred/released? X=Needs to be bolded in the CRJC=Only in Joint Commission Overlay#=Outcome needs to add to Coverdell Overlay Effective for discharges 10/1/10 and later @=Abstract for cases discharged prior to 10/1/10

Source: http://www.mnstrokeregistry.net/documents/DataElementCrosswalk110103.pdf