Defect free acute inpatient ischemic stroke measure bundle

Measure bundle purpose: Ensure patients receive optimal acute inpatient care.

The numerator has three components, all of which must be met:

*See measure specifications for complete definitions.

1. Antithrombotic therapy* received by end of hospital day two OR documentation of medical/patient exception
2. Antithrombotic therapy prescribed* at discharge 
   1. Appropriate antithrombotic for patients with stroke AND non valvularatrial fibrillation using therapeutic anticoagulation (warfarin, LMWH or direct factor inhibitors as approved by FDA), OR documentation of medical/patient exception,
   2. Appropriate antithrombotic for patients with stroke AND mechanical heart valve or valvular atrial fibrillation using anticoagulation with warfarin OR documentation of medical/patient exception, OR
   3. Appropriate antithrombotic for all other patients with stroke using antiplatelet or therapeutic anticoagulation
Patients with ischemic stroke who have documentation of active smoking status* OR former smoker with quit date less than 1 year from time of assessment provided counseling on the bad effects of tobacco, the benefit of quitting AND at least one of the following:
1. Referral back to PCP for tobacco cessation support, AND/OR
2. Referral to tobacco cessation clinic or tobacco-dependent telephone quitline, AND/OR
3. Prescription of tobacco dependence medications including nicotine replacement therapies products, bupropion SR or Varenicline, or any FDA-approved drugs for tobacco dependence therapies or referral to PCP

is divided by

the denominator:  All acute ischemic stroke and transient ischemic attack patients aged 18 years and older admitted for inpatient care.

Exclusions are removed from the denominator:

For all components:

• Patients discharged to hospice
• Patients who were placed on comfort measures by end of hospital day two
• Patient died by end of hospital day two.
• Patient enrolled in a clinical trial
• Patient declines treatment or discharged against medical advice by end of hospital day two.
• Patients with documented contraindication to specific intervention.

Key Phrases

Examples of key phrases you could use to meet the measure include:

• early antithrombotic therapy prescribed
• antithrombotic therapy prescribed at discharge
• Patient is not an active smoker
• Patient counseled on risks of smoking, benefits of quitting, and referred to tobacco cessation supports

Measure Calculation Example

This measure utilizes an all-or-none calculation strategy. 

Dr. Zhang treats 5 patients (A, B, C, D, and E) between January 1 and December 31 that were diagnosed with acute ischemic stroke or transient ischemic attach aged 18 years and older while they were admitted for inpatient care.

• All five patients A, B, C, D, and E had documentation of a prescription for an early anthrombotic.
• Four patients A, B, D, and E were discharged with a prescription for antithrombotic therapy. C did not.
• All five patients A, B, C, D, and E had documentation they were either a non-smoker for greater than 1 year or tobacco use management if an active smoker.

Dr. Zhang's performance rate is 80% for this measure. 4 patients (A, B, D, E) met the bundle/5 patients in the denominator.