NQMC Update Service: August 3, 2015 ► The Joint Commission

NQMC Update Service: August 3, 2015

The Joint Commission

• Heart failure (HF): percentage of HF patients discharged from a hospital inpatient setting to home or home care for whom a care transition record is transmitted to a next level of care provider within 7 days of discharge containing the specified information.

• Heart failure (HF): percentage of HF patients discharged from a hospital inpatient setting to home or home care for whom a follow-up appointment for an office or home health visit for management of HF was scheduled within 7 days post-discharge and documented including location, date, and time.

• Heart failure (HF): percentage of HF patients discharged from a hospital inpatient setting to who have a documented re-evaluation for symptoms worsening and treatment compliance conducted within 72 hours after discharge.

• Heart failure (HF): percentage of HF patients who are prescribed bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD at hospital discharge.

• Heart failure (HF): percentage of HF patients who have documentation in the medical record of a one-time discussion of advance directives/advance care planning with a healthcare provider.

• Heart failure (HF): percentage of HF patients who have documentation in the medical record that an advance directive was executed.

• Stroke: median time from hospital arrival to the start of an IA thrombolytic (t-PA) infusion or the first pass (i.e., deployment) of a mechanical reperfusion device to extract an arterial occlusive lesion and restore blood flow to brain tissue.

• Stroke: percentage of ICH stroke patients with an INR value greater than 1.4 at hospital arrival who are treated with a procoagulant reversal agent.

• Stroke: percentage of ischemic stroke patients for whom an initial National Institutes of Health Stroke Scale (NIHSS) score is performed prior to any acute recanalization therapy in patients undergoing recanalization therapy and documented in the medical record, OR documented within 12 hours of arrival at the hospital ED for patients who do not undergo recanalization therapy.

• Stroke: percentage of ischemic stroke patients treated with IV or IA thrombolytic (t-PA) therapy or who undergo mechanical endovascular reperfusion therapy for whom a 90 day (greater than or equal to 75 days and less than or equal to 105 days) Modified Rankin Scale (mRS) is obtained via telephone or in-person.

• Stroke: percentage of ischemic stroke patients who develop a symptomatic intracranial hemorrhage within (less than or equal to) 36 hours after the onset of treatment with IV or IA thrombolytic (t-PA) therapy, or mechanical endovascular reperfusion procedure.

• Stroke: percentage of ischemic stroke patients with a post-treatment reperfusion grade of thrombolysis in cerebral infarction (TICI) 2B or higher in the vascular territory beyond the target arterial occlusion at the end of treatment with IA thrombolytic (t-PA) therapy and/or mechanical endovascular reperfusion therapy.

• Stroke: percentage of SAH and ICH stroke patients for whom a severity measurement is performed prior to surgical intervention in patients undergoing surgical intervention and documented in the medical record, OR documented within 6 hours of arrival at the hospital ED for patients who do not undergo surgical intervention.

• Stroke: percentage of SAH patients for whom nimodipine treatment was administered within 24 hours of arrival at the hospital.