DATA COLLECTION AND DATA REPORTING TOOLS

**STROKE**

***Introduction***

These tools have been developed as one option for collecting and
reporting DSC stroke measure data. Your organization may choose to
design manual data collection and reporting tools of your own or develop
an electronic format for data collection and data reporting. These data
tools have been created with the following objectives:

-   Minimize unnecessary entries;

-   Expedite and streamline the data collection process; and

-   Facilitate data aggregation for measure rate calculations and report
    submission.

The data elements included in these tools could be added to an existing
data collection tool or program within your organization or your
organization may wish to add other data elements to these forms with a
goal of avoiding duplicative or multiple data abstraction activities.
Combining data collection efforts may support additional performance
improvement initiatives as well.

***Guide to Use***

1)  Always complete the report period information. This is critical
    since a single patient/participant might be included in multiple
    report periods.

2)  Always complete questions 1-12. These data elements capture
    fundamental population inclusion criteria and will avoid the
    collection of data for patients who are not eligible for any measure
    populations.

3)  Always complete one data collection tool per patient case.

4)  Aggregate Category D and Category E responses from each ***Data
    Collection Tool*** and complete the ***Data Reporting Tool*** to
    calculate rates.

5)  **It is very important that the data definitions and abstraction
    guidelines included in the Data Element Dictionary (Section 5) of
    the *Stroke Performance Measurement Implementation Guide* be used
    when abstracting data for these measures.**

**DATA COLLECTION TOOL**

**STROKE**

Report Period (Month) Note: Time period for inpatients is based on the
patient's discharge date

 January  February  March  April  May  June

 July  August  September  October  November  December

Year \_\_\_ \_\_\_ \_\_\_ \_\_\_

**Core Data** **Elements**

1\) Case ID #\_\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_ 2) Treated at a
DSC Certified Primary Stroke Center Program

a\)  Yes b)  No (Stop)

3\) Gender  Male  Female 4) Birth Date \_\_\_ \_\_\_ / \_\_\_ \_\_\_ /
\_\_\_ \_\_\_ \_\_\_ \_\_\_

5\) Age 18 years or older  a) Yes  b) No (Stop)

6\) Arrival Date \_\_\_ \_\_\_ / \_\_\_ \_\_\_ / \_\_\_ \_\_\_ \_\_\_
\_\_\_ 7) Arrival Time (military) \_\_\_ \_\_\_ : \_\_\_ \_\_\_

8\) Admission Date \_\_\_ \_\_\_ / \_\_\_ \_\_\_ / \_\_\_ \_\_\_ \_\_\_
\_\_\_ 9) Discharge Date \_\_\_ \_\_\_ / \_\_\_ \_\_\_ / \_\_\_ \_\_\_
\_\_\_ \_\_\_

10\) Admitted for Elective Carotid Endarterectomy

 a) Yes (Stop)  b) No

11\) Discharge Status

 01 Discharged to home care or self care (routine discharge)

 02 Discharged/transferred to another short term general hospital for
inpatient care

 03 Discharged/transferred to a skilled nursing facility (SNF) with
Medicare certification

 04 Discharged/transferred to an intermediate care facility

 05 Discharged/transferred to another type of institution for inpatient
care

 06 Discharged/transferred to home under care of organized home health
service organization

 07 Left against medical advice or discontinued care

 20 Expired

 41 Expired in medical facility, such as hospital, SNF, ICF or
freestanding hospice (Hospice). [Usage Note:]{.underline} For use only
on Medicare and CHAMPUS (TRICARE) claims for hospice care.

 43 Discharged/transferred to a federal health care facility (e.g.,
Department of Defense hospital, Veterans Administration hospital or
nursing facility)

 50 Hospice - home

 51 Hospice - medical facility

 61 Discharged/transferred within this institution to hospital-based
Medicare approved swing bed. [Usage Note:]{.underline} Medicare-used for
reporting patients discharged/transferred to a SNF level of care within
a hospital's approved swing bed arrangement.

 62 Discharged/transferred to an inpatient rehabilitation facility
(IRF) including rehabilitation distinct part units of a

hospital

 63 Discharged/transferred to a Medicare certified long term care
hospital (LTCH)

 64 Discharged/transferred to a nursing facility certified under
Medicaid but not certified under Medicare

 65 Discharged/transferred to a psychiatric hospital or psychiatric
distinct part unit of a hospital

 66 Discharged/transferred to a Critical Access Hospital (CAH)

 \-\-- Unknown \-\--

12\) ICD-9-CM Diagnosis Codes

Principal \_\_\_ \_\_\_ \_\_\_ . \_\_\_ \_\_\_

Other \_\_\_ \_\_\_ \_\_\_ . \_\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_ . \_\_\_
\_\_\_ \_\_\_ \_\_\_ \_\_\_ . \_\_\_ \_\_\_

\_\_\_ \_\_\_ \_\_\_ . \_\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_ . \_\_\_
\_\_\_ \_\_\_ \_\_\_ \_\_\_ . \_\_\_ \_\_\_

\_\_\_ \_\_\_ \_\_\_ . \_\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_ . \_\_\_
\_\_\_ \_\_\_ \_\_\_ \_\_\_ . \_\_\_ \_\_\_

ICD-9-CM Principal Diagnosis Codes for Ischemic Stroke: All 10 Measures

ICD-9-CM Prinipal Diagnosis Codes 430 & 431, Hemorrhagic Stroke: STK-1;
STK-7; SKT-8; STK-9; STK-10

(See Appendices Table 1 & Table 2)

**DSC STK-1: DVT Prophylaxis**

13\) Patient discharged before the end of hospital day two  a) Yes
(Stop)  b) No

14\) Patient ambulatory at end of hospital day two  a) Yes (Stop)  b)
No

15\) Comfort Measures Only by end of hospital day two  a) Yes (Stop) 
b) No

16\) DVT prophylaxis initiated by the end of hospital day two

 a) Yes (This patient is in Category E)

 b) No (This patient is in Category D)

 c) NC -- a documented reason exists (Stop)

**DSC STK-2: Discharged on Antithrombotic Therapy** (ICD-9-CM Principal
Diagnosis Codes for Ischemic Stroke Only)

17\) Discharge Status

 a) = 02, 07, 20, 41, 50, 51, 66, Unknown (Stop)

 b) = 01, 03, 04, 05, 06, 43, 61, 62, 63, 64, 65

18\) Comfort Measures Only  a) Yes (Stop)  b) No

19\) Antithrombotic therapy prescribed at discharge

 a) Yes (This patient is in Category E)

 b) No (This patient is in Category D)

 c) NC-- a documented reason exists (Stop)

**DSC STK-3: Patients with Atrial Fibrillation Receiving Anticoagulation
Therapy**

(ICD-9-CM Principal Diagnosis Codes for Ischemic Stroke Only)

20\) Discharge Status

 a) = 02, 07, 20, 41, 50, 51, 66, Unknown (Stop)

 b) = 01, 03, 04, 05, 06, 43, 61, 62, 63, 64, 65

21\) Comfort Measures Only  a) Yes (Stop)  b) No

22\) Atrial Fibrillation (atrial flutter, paroxysmal atrial fibrillation
(PAF))

 a) Yes

 b) No (Stop)

23\) Patient discharged on anticoagulation therapy

 a) Yes (This patient is in Category E)

 b) No (This patient is in Category D)

 c) NC-- a documented reason exists (Stop)

**DSC STK-4: Thrombolytic Therapy Administered** (ICD-9-CM Principal
Diagnosis Codes for Ischemic Stroke Only)

24\) Date Last Known Well *(MM/DD/YYYY)*  a) \_\_\_ \_\_\_ / \_\_\_
\_\_\_/ \_\_\_ \_\_\_ \_\_\_ \_\_\_

25\) Time Last Known Well *(Hour 00-23 / Min. 00-59)*  a) \_\_\_
\_\_\_: \_\_\_ \_\_\_

>  b) ND (time not documented or unknown at the time the treatment
> decision was made)

26\) Arrival Time (military) \_\_\_ \_\_\_ : \_\_\_ \_\_\_ (Question 7)

27\) Compute: Arrival Time -- (minus) Time Last Known Well: \_\_\_
\_\_\_: \_\_\_ \_\_\_ -- (minus) \_\_\_ \_\_\_: \_\_\_ \_\_\_ = \_\_\_:
\_\_\_ \_\_\_

28\) Arrival Time -- (minus) Time Last Known Well is less than or equal
to 2 hrs (120 min)  a) Yes  b) No (Stop)

29\) IV thrombolytic administered to the patient at this hospital

>  a) Yes
>
>  b) No (This patient is in Category D)
>
>  c) NC-- a documented reason exists (Stop)

30\) Date IV thrombolytic administered at this hospital \_\_\_ \_\_\_ /
\_\_\_ \_\_\_ / \_\_\_ \_\_\_ \_\_\_ \_\_\_\_

31\) Time IV thrombolytic administered at this hospital (military)
\_\_\_ \_\_\_ : \_\_\_ \_\_\_  b) ND (time not documented or unknown at
the time the treatment decision was made)

32\) Compute: Time IV Thrombolytic Administered at this Hospital --
(minus) Time Last Known Well:

\_\_\_ \_\_\_: \_\_\_ \_\_\_ -- (minus) \_\_\_ \_\_\_: \_\_\_ \_\_\_ =
\_\_\_: \_\_\_ \_\_\_

33\) IV thrombolytic administered in less than or equal to 3 hrs (180
min) of time of last known well

 a) Yes (This patient is in Category E)  b) No (This patient is in
Category D)

**DSC STK-5: Antithrombotic Therapy By End of Hospital Day Two**

(ICD-9-CM Principal Diagnosis Codes for Ischemic Stroke Only)

34\) Patient discharged by end of hospital day two  a) Yes (Stop)  b)
No

35\) Comfort Measures Only by end of hospital day two  a) Yes (Stop) 
b) No

36\) Antithrombotic therapy administered by the end of hospital day two

 a) Yes (This patient is in Category E)

 b) No (This patient is in Category D)

 c) NC -- a documented reason exists (Stop)

**DSC STK-6: Discharged on Cholesterol Reducing Medication**

(ICD-9-CM Principal Diagnosis Codes for Ischemic Stroke Only)

37\) Discharge Status

 a) = 02, 07, 20, 41, 50, 51, 66, Unknown (Stop)

 b) = 01, 03, 04, 05, 06, 43, 61, 62, 63, 64, 65

38\) Comfort Measures Only  a) Yes (Stop)  b) No

39\) Cholesterol reducing therapy prior to hospitalization  a) Yes
(Skip 40 & 41 )  b) No

40\) LDL Measured  a) Yes  b) No (Skip 41)

41\) LDL [\>]{.underline} 100 mg/dL  a) Yes  b) No (Stop)

42\) Cholesterol reducing medication prescribed at discharge

 a) Yes (This patient is in Category E)

 b) No (This patient is in Category D)

 c) NC-- a documented reason exists (Stop)

**DSC STK-7: Dysphagia Screening**

43\) No oral intake (NPO) of food, fluid, or medication for entire
hospital stay

 a) Yes (Stop)  b) No

44\) Dysphagia screen performed prior to oral intake

 a) Yes (This patient is in Category E)

 b) No (This patient is in Category D)

 c) NC-- a documented reason exists (Stop)

**DSC STK-8: Stroke Education**

45\) Discharge Status

 a) = 02, 07, 20, 41, 50, 51, 66, Unknown (Stop)

 b) = 01, 03, 04, 05, 06, 43, 61, 62, 63, 64, 65

46\) Comfort Measures Only  a) Yes (Stop)  b) No

47\) Education addresses activation of EMS (Patient and/or caregiver
received education and/or resource materials)

 a) Yes

 b) No

 c) NC-- a documented reason exists (Stop)

48\) Education addresses need for follow-up after discharge from
hospital

(Patient and/or caregiver received education and/or resource materials)

 a) Yes

 b) No

 c) NC-- a documented reason exists (Stop)

49\) Education addresses medications prescribed (Patient and/or
caregiver received education and/or resource materials)

 a) Yes

 b) No

 c) NC-- a documented reason exists (Stop)

50\) Education addresses personal risk factors for stroke (Patient
and/or caregiver received education and/or resource materials)

 a) Yes

 b) No

 c) NC-- a documented reason exists (Stop)

51\) Education addresses warning signs and symptoms of stroke

(Patient and/or caregiver received education and/or resource materials)

 a) Yes

 b) No

 c) NC-- a documented reason exists (Stop)

52\) Yes checked for all 5 education questions 47 -- 51

 a) Yes (This patient is in Category E)

 b) No (This patient is in Category D)

**DSC STK-9: Smoking Cessation / Advice / Counseling**

53\) Discharge Status

 a) = 02, 07, 20, 41, 50, 51, 66, Unknown (Stop)

 b) = 01, 03, 04, 05, 06, 43, 61, 62, 63, 64, 65

54\) Comfort Measures Only  a) Yes (Stop)  b) No

55\) Adult Smoking History  a) Yes  b) No (Stop)

56\) Smoking cessation / advice / counseling was given to the patient or
caregiver during the hospital stay

 a) Yes

 b) No

 c) NC-- a documented reason exists (Stop)

**DSC STK-10: Assessed for Rehabilitation**

57\) Discharge Status

 a) = 02, 07, 20, 41, 50, 51, 66, Unknown (Stop)

 b) = 01, 03, 04, 05, 06, 43, 61, 62, 63, 64, 65

58\) Comfort Measures Only  a) Yes (Stop)  b) No

59\) Patient assessed for or received rehabilitation services

 a) Yes (This patient is in Category E)

 b) No (This patient is in Category D