Hospital Metrics and Data Elements

Learn more about data elements and metrics collected through the Paul Coverdell National Acute Stroke Program (PCNASP).

Hospital Data Elements

Data elements in white cells are required; data elements in blue cells are optional; data elements in orange are unique to the PCNASP, and are not required by other in-hospital acute stroke quality improvement programs. View the data elements [Excel-31K].

Hospital Metrics

Inclusion into the Coverdell Registry and calculation of these metrics are based on the final clinical diagnosis of stroke, rather than the principle ICD-10-CM diagnosis code.

Venous Thromboembolism (VTE) Prophylaxis (NQF 0434)
Ischemic and hemorrhagic stroke patients and stroke not otherwise specified who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission.

Discharged on Antithrombotic Therapy (NQF 0435)
Ischemic stroke and TIA patients prescribed antithrombotic therapy at hospital discharge.

Anticoagulation Therapy for Atrial Fibrillation/Flutter (NQF 0436)
Ischemic stroke and TIA patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge.

Thrombolytic Therapy (NQF 0437)
Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours of time last known well.

Antithrombotic Therapy by End of Hospital Day 2 (NQF 0438)
Ischemic stroke and TIA patients administered antithrombotic therapy by the end of hospital day 2.

Discharged on Statin Medication (NQF 0439)
Ischemic stroke and TIA patients with LDL greater than or equal to 100 mg/dL, or LDL not measured, or who were on a lipid-lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge.

Stroke Education (NQF 0440)
Ischemic or hemorrhagic stroke patients and stroke not otherwise specified and TIA patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke.

Assessed for Rehabilitation (NQF 0441)
Patients assessed for rehabilitation services after experiencing an ischemic or hemorrhagic stroke or stroke not otherwise specified.

Smoking Cessation Counseling
Ischemic or hemorrhagic stroke patients or stroke not otherwise specified and TIA patients who are current smokers who receive or refuse smoking cessation counseling.

Dysphagia Screening (NQF 0243)
Patients aged 18 years and older with a diagnosis of ischemic stroke or hemorrhagic stroke or stroke not otherwise specified who receive any food, fluids, or medication by mouth (PO) for whom a dysphagia screening was performed prior to PO intake in accordance with a dysphagia screening tool approved by the institution in which the patient is receiving care.

Recording of NIH Stroke Scale Score (NQF 1955–not endorsed)
Patients aged 18 and older with ischemic stroke, or stroke not otherwise specified, with an initial NIH Stroke Scale recorded.

Patients with acute ischemic stroke who receive intravenous tissue plasminogen activator (tPA) who have an NIH stroke scale score recorded.

Time to intravenous thrombolytic therapy (NQF 1952)
Acute ischemic stroke patients aged 18 years and older receiving intravenous tPA therapy during the hospital stay and having a time from hospital arrival to initiation of thrombolytic therapy administration (door-to-needle time) of 60 minutes or less.

Median time from hospital arrival to administration of intravenous tissue plasminogen activator (tPA) therapy in acute ischemic stroke patients aged 18 years and older.

Door to brain imaging time (NQF 0661)
Head CT Scan Interpretation within 45 minutes of arrival for acute ischemic stroke or hemorrhagic stroke patients who arrive within 2 hours of time last known well who received head CT. (Alternatively, head CT scan completed within 25 minutes of arrival for acute ischemic stroke or hemorrhagic stroke patients who arrive within 2 hours of time last known well.)