Potentially avoidable complications following stroke

Measure bundle purpose: Reduce potentially avoidable complications following stroke.

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

1. Deep Vein Thrombosis (DVT) or pulmonary embolism (PE)
2. Aspiration pneumonia
3. Fall as defined as an unplanned descent to the floor with or without injury
4. Urinary Tract Infection (UTI)
5. Stage II or greater decubiti

is divided by

the denominator:  all patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage.

Exclusions are removed from the denominator:
For all components, except component 3 (Falls):

• Patients who were placed on palliative/comfort measures during stay before complication occurred (performance tracked performance until decision made to place on palliative measures; then after that decision made no longer score.)

For component 1:

• Patients who had an in-hospital stroke,
• Patients who died during the hospitalization within 48 hours of admission
• DVT developed within 48 hours of admission or present on admission

For component 2:

• Diagnosed within 48 hours of the hospitalization or inpatient stroke event
• Patients who died during the hospitalization within 48 hours of admission

For component 3:

• None

For component 4:

• In-hospital stroke (link to onset of stroke event) within 48 hours,
• Patients who died during the hospitalization within 48 hours,
• UTI developed within 48 hours of hospitalization or present on admission

For component 5:

• Inpatient stroke events within 48 hours
• Documentation of presence of decubitus ulcer on admission

Key Phrases

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

• PE occurred
• DVT identified/diagnosed
• Diagnosed with aspiration pneumonia
• Pt fell on unit
• Diagnosed with UTI
• Diagnosed with stage III decubiti

Measure Calculation Example

This measure utilizes an all-or-none calculation strategy, and is an inversive measure. Lower performance is indicative of higher quality of care. 0% is not the goal, but a lower score is better.

For a more comprehensive explanation of how measure bundles are calculated please view this 17-minute webinar (download).

Dr. Yang oversees care for 5 patients (A, B, C, D, and E) between January 1 and December 31 that were 18 years and older diagnosed with ischemic stroke or intracranial hemorrhage.

• None of the five patients A, B, C, D, and E had a DVT or PE documented.
• C developed aspiration pneumonia during her admission; four patients A, B, D, and E did not.
• None of the five patients A, B, C, D, and E had a fall documented.
• Four patients A, B, C, and E did not develop a UTI. D developed a UTI within 48 hours of hospitalization and met exclusion criteria. D is removed from the denominator for this component.
• None of the five patients A, B, C, D, and E had stage II or greater decubiti documented.

Dr. Yang's performance rate is 20% for this measure. 1 patient (E) met the bundle/5 patients (D removed from component 4) in the denominator.