Stroke Patient Management Tool (Standard, CM, Comprehensive) December 2014

Patient ID: ADMIN Stroke Patient Management Tool (Standard, CM, Comprehensive) December 2014 Final clinical diagnosis related to stroke If No Stroke Related Diagnosis: ICD-9-CM Principal Diagnosis Code ICD-9-CM Other Diagnosis Codes Ο Ischemic Stroke Ο Transient Ischemic Attack (< 24 hours) Ο Subarachnoid Hemorrhage Ο Migraine Ο Seizure Ο Delirium.. ICD-9-CM Principal Procedure Code. ICD-9-CM Other Procedure Codes. ^What was the ICD-9-CM diagnosis code selected as the admitting diagnosis for this patient? When is the earliest documentation of comfort measures only? For patients discharged on or after 04/01/2011: What was the patient s discharge disposition on the day of discharge? If Other Health Care Facility. Bold Question = Required ^CSTK Comprehensive Stroke Element ^^GWTG only Comprehensive Stroke Element Admin Tab Ο Intracerebral Hemorrhage Ο Stroke not otherwise specified stroke related diagnosis Ο Elective Carotid Intervention only Ο Electrolyte or metabolic imbalance Ο Functional disorder Ο Other Ο Uncertain Ο Day 0 or 1 Ο Day 2 or after Ο Timing unclear t Documented/UTD 1 Home 2 Hospice Home 3 Hospice Health Care facility 4 Acute Care Facility 5 Other Health Care facility 6 Expired 7 Left Against Medical Advise/AMA 8 Not Documented or Unable to Determine (UTD) Ο Inpatient Rehabilitation Facility (IRF) Ο Intermediate Care facility (ICF) Ο Long Term Care Hospital (LTCH) Ο Skilled Nursing Facility (SNF) Ο Other ARRIVAL AND ADMISSION INFORMATION Admission Tab During this hospital stay, was the patient enrolled in a clinical trial in which patients with the same condition as the measure set were being studied (i.e. AMI, CAC, HF, PN, PR, SCIP, STK,VTE)? Was this patient admitted for the sole purpose of performance of elective carotid intervention? t in a healthcare setting Ο Outpatient healthcare setting Patient location when stroke Ο Another acute care facility Ο Stroke occurred after hospital arrival (in ED/Obs/inpatient) symptoms discovered Ο Chronic health care facility Ο ND or Cannot be determined How patient arrived at your hospital Ο EMS from home/scene Ο Private transportation/taxi/other from home/scene Was the patient an ED patient at the facility? ^Was the patient a direct admission to the hospital? Where patient first received Ο Emergency Department/ Urgent Ο Direct Admit, not care at your hospital Care through ED Advanced notification by EMS? /ND Ο N/A Arrival Date/Time: Ο Transfer from another hospital Ο Imaging suite Admit Date: Ο ND or Unknown Ο ND or Cannot be determined / / Stroke form -NOT FOR USE WITHOUT PERMISSION. 2014 American Heart Association and Quintiles. Page 1

Not Admitted: Stroke Patient Management Tool (Standard, CM, Comprehensive) December 2014, not admitted, patient admitted as inpatient Where was the patient cared for and by whom? Check all that apply. Physician/Provider NPI: Reason Not Admitted: Neuro Admit Stroke Consult In Stroke Unit Ο Transferred from your ED to another acute care hospital Ο Discharged directly from ED to home or other location that is not an acute care hospital Ο Left from ED AMA Ο Died in ED Ο Discharged from observation status without an inpatient admission Ο Other Other Service Admission No Stroke Consult Not in Stroke Unit DEMOGRAPHICS Date of Birth: / / Age: Gender: Ο Male Ο Female Ο Unknown Hispanic Ethnicity: /UTD Specify Hispanic Ethnicity (see Coding Key) Race: (Check all that apply) Ο American Indian /Alaska Native Ο Asian Specify Asian (see Coding Key) Ο Black or African American Ο Native Hawaiian or Pacific Islander Specify Native Hawaiian or Pacific Islander (see Coding Key) Ο White Ο UTD Health Insurance Status: What is the patient's source of payment for this episode of care? Medicare Self Pay/No Insurance Ο Medicare n-medicare Medicaid Private/VA/Champus/Other Insurance Zip Code: - Homeless MEDICAL HISTORY None Atrial Fib/Flutter CAD/Prior MI Carotid Stenosis Previously known medical hx of: (Select all that apply) Ambulatory status prior to current event DIAGNOSIS & EVALUATION Symptom Duration if diagnosis of Transient Ischemic Attack (< 24 hours) Current Pregnancy (or up to 6 weeks post Depression Diabetes Mellitus partum) Drugs/Alcohol Abuse Dyslipidemia Family History of Stroke HF HRT Hypertension Migraine Obesity/Overweight Previous Stroke Previous TIA Prosthetic Heart Valve PVD Renal insufficiency chronic (SCr>2.0) Smoker Sickle Cell Sleep Apnea Ο Able to ambulate independently (no help from another person) w/ or w/o device Ο With assistance (from person) Ο Unable to ambulate Ο ND Ο 10-59 Ο Less than 10 minutes minutes Had stroke symptoms resolved at time of presentation? Ο ND Initial NIH Stroke Scale /ND If Yes: Ο Actual Ο Estimated from the record Ο ND Ο > 60 minutes Ο ND Stroke form -NOT FOR USE WITHOUT PERMISSION. 2014 American Heart Association and Quintiles. Page 2

Total Score (refer to web program for questions) ^What is the first NIHSS score obtained prior to or after hospital arrival? ^ Is there documentation that an initial ^Initial NIHSS Score Date and NIHSS score was done at this hospital? Time NIHSS score obtained from transferring facility: Weakness/Paresis Altered Level of Aphasia/Language Disturbance Initial exam findings Consciousness (Select all that apply) No neurological signs/symptoms Ambulatory status on admission Hemorrhagic Stroke Scales Ο Able to ambulate independently (no help from another person) w/ or w/o device Ο With assistance (from person) Ο Unable to ambulate Ο ND UTD Other neurological signs/symptoms ^^First Glasgow Coma Scale (GCS) Eye Verbal Intubated Motor Total GCS Intracerebral Hemorrhage (ICH) ^Was an initial ICH score done at this hospital? ^^If yes, ICH score: ^What is the date and time that the ICH score was first performed at this hospital? ^^FUNC Score (ICH) Subarachnoid Hemorrhage (SAH) ^Was an initial Hunt and Hess scale done at this hospital? ^^If yes, Hunt and Hess score: ^What is the date and time that the Hunt and Hess Scale was first performed at this hospital? ^^WFNS SAH Grading Scale MEDICATIONS PRIOR TO ADMISSION No medications prior to admission Antiplatelet or Anticoagulant Medication(s): /ND Antiplatelet aspirin aspirin/dipyridamole (Aggrenox) clopidogrel (Plavix) prasugrel (Effient) ticagrelor (Brilinta) ticlopidine (Ticlid) Other Antiplatelet Unfractionated heparin IV full dose LMW heparin warfarin (Coumadin) dabigatran (Pradaxa) argatroban desirudin (Iprivask) fondaparinux (Arixtra) rivaroxaban (Xarelto) apixaban (Eliquis) lepirudin (Refludan) Other Anticoagulant Antihypertensive /ND Cholesterol-Reducer /ND Diabetic medication /ND Antidepressant medication /ND SYMPTOM TIMELINE Time of Discovery Date/Time patient last known to be well? same as Last known well Anticoagulant Hospitalization Tab Date/Time of discovery of stroke symptoms? Stroke form -NOT FOR USE WITHOUT PERMISSION. 2014 American Heart Association and Quintiles. Page 3

Comments BRAIN IMAGING Brain imaging completed at your hospital for this episode of care? MM/DD/YYYY only /ND Ο NC Date/Time Brain Imaging Initiated Interpretation of first brain image after symptom onset, done at any facility: ADDITIONAL TIME TRACKER See Target: Stroke Patient Time Tracker for data elements IV THROMBOLYTIC THERAPY IV t-pa initiated at this hospital? Documented Contraindications or Warnings for not initiating IV thrombolytic in the 0-3hr treatment window? Documented Contraindications or Warnings for not initiating IV thrombolytic in the 3-4.5hr treatment window? MM/DD/YYYY only Ο Hemorrhage Hemorrhage t Available Date/Time IV tpa initiated: Additional Warnings for patients treated between 3-4.5 hrs (see Coding Key) If no documented contraindications 0-3hr 3-4.5hr or warnings, Hospital-Related or Delay in Patient Arrival Other Factors In-hospital Time Delay Delay in Stroke diagnosis If IV tpa was initiated greater than 60 minutes after hospital arrival, were Eligibility or Medical reason(s) documented as the cause for delay: Delay in stroke diagnosis If no documented eligibility or medical In-hospital time delay reason(s), Hospital Related or Other Equipment-related delay Reason(s) Other Reasons (see Coding Key) Reasons (see Coding Key) WAS OTHER THROMBOLYTIC/REPERFUSION THERAPY ADMINISTERED? IV tpa at an outside hospital? IA catheter-based treatment at this hospital? IA t-pa or MER Initiation Date/Time ^Is there documentation that the route of thrombolytic (t-pa) administration at this hospital was intra-arterial (IA)? ^Is there documentation that IA thrombolytic therapy was initiated at this hospital? ^Is there documentation in the medical record of the first pass of a mechanical reperfusion device to remove a clot occluding a cerebral artery at this hospital? ^What is the date & time of the First Pass? 0-3hr 3-4.5hr No IV access Other ^^Arterial puncture Date/Time ^Date/Time associated with IA thrombolytic therapy initiated for this patient at this hospital: Reasons (see Coding Key) Stroke form -NOT FOR USE WITHOUT PERMISSION. 2014 American Heart Association and Quintiles. Page 4

^^If MER treatment at this hospital, type of treatment: ^Proximal or distal occlusion ^What cerebral artery is occluded? Retrievable stent Other mechanical clot retriever device (not retrievable stent) Clot suction device Intracranial angioplasty, with or without permanent (non-retrieved stent) Cervical carotid angioplasty, with or without stent Other Ο The clot location is proximal Ο The clot location is distal Ο Neither proximal or distal are documented in reference to the location of the clot in the cerebral circulation or UTD from medical record documentation Ο Anterior cerebral artery (ACA) Ο A1 ACA Ο Anterior communicating artery Ο Cervical internal carotid artery (ICA) Ο Intracranial ICA Ο Middle cerebral artery (MCA) Ο M1 MCA Ο M2 MCA Ο M3/M4 MCA Ο Vertebral artery (VA) Ο Basilar artery (BA) Ο Posterior communicating artery (PCA) Ο Other cerebral artery branch/segment Ο The clinical location of the primary occluded vessel was not documented, OR unable to determine (UTD) from the medical record documentation ^Did the patient receive intravenous (IV) thrombolytic (t-pa) therapy at this hospital or a transferring hospital prior to receiving intra-arterial (IA) thrombolytic therapy or mechanical reperfusion therapy at this hospital? Investigational or experimental protocol for thrombolysis? ^^Thrombolysis in Cerebral Infarction (TICI) Post- Treatment Reperfusion Grade ^Is there a documented TICI reperfusion grade post treatment? ^^Surgical treatment for ICH at this hospital? ^^ If surgical treatment for ICH at this hospital, type: ^^ If ICH was evacuated, time from ictus to evacuation procedure start was: Additional Comments Related to Thrombolytics If yes, specify Ο Grade 0 Ο Grade 1 Ο Grade 2a Ο Grade 2b Ο Grade 3 Ο 1- A TICI reperfusion grade greater than or equal to 2b was documented post treatment IN-HOSPITAL TREATMENT AND COMPLICATIONS Complications of Thrombolytic Therapy Ο 2- A TICI reperfusion grade less than 2b was documented post treatment Ο 3 - A TICI reperfusion grade was not done post treatment, OR UTD from medical record documentation External Ventricular Drain (EVD) Endoscopic evacuation Conventional craniotomy and evacuation of clot under direct vision Stereotactic evacuation Hemicraniectomy without clot evacuation Fibrinolytic infusion via catheter Other (hours) Symptomatic intracranial hemorrhage <36 hours Life threatening, serious systemic hemorrhage <36 hours UTD Other serious complications No serious complications Stroke form -NOT FOR USE WITHOUT PERMISSION. 2014 American Heart Association and Quintiles. Page 5

If bleeding complications occur in patient transferred after IV tpa: ^ What is the last NIHSS score documented prior to initiation of IV thrombolytic therapy at this hospital? ^What is the highest NIHSS score documented within 36 hours following initiation of IV (t-pa) thrombolytic therapy? ^ Was there a positive finding on brain imaging of parenchymal hematoma, SAH, and or IVH following IV or IA t- PA, OR mechanical endovascular reperfusion therapy initiation? ^^Results of positive brain image Ο Symptomatic hemorrhage detected prior to patient transfer Ο Symptomatic hemorrhage detected only after patient transfer UTD UTD ^Is there documentation that a procogulant reversal agent was initiated at this hospital? ^Is there documentation by a physician/apn/pa or pharmacist in the medical record of a reason for not administering a procoagulant reversal agent? ^^Date/Time procoagulant initiated Ο Unable to determine Ο N/A ^ What is the last NIHSS score documented prior to initiation of IA t-pa or MER at this hospital? ^What is the highest NIHSS score documented within 36 hours following IA t-pa or MER initiation? ^Date/Time of positive brain image UTD UTD PH2 (Parenchymal Hematoma Type 2) IVH (Intraventricular Hemorrhage) SAH (Subarachnoid Hemorrhage) RIH (Remote site of intraparenchymal hemorrhage outside the area of infarction) Other positive finding not listed above Not documented ^Is there documentation that nimodipine was administered at this hospital (SAH)? ^Is there documentation by a physician/apn/pa or pharmacist in the medical record of a reason for not administering nimodipine treatment? ^What is the date and time of nimodipine administration for this patient at this hospital? Dysphagia Screening Patient NPO throughout the entire hospital stay? /ND Was patient screened for dysphagia prior to any oral intake including water or medications? /ND Ο NC If yes, Dysphagia screening results: Ο Pass Ο Fail Ο ND Treatment for Hospital-Acquired Pneumonia Ο NC 5- Factor Xa Inhibitor 1- Low dose unfractionated heparin (LDUH) 6- Warfarin 2- Low molecular weight heparin (LMWH) VTE 7- Venous foot pumps (VFP) 3- Intermittent pneumatic compression devices Interventions 8- Oral Factor Xa Inhibitor (IPC) 9- Aspirin 4- Graduated compression stockings (GCS) A- None of the above or ND What date was the initial VTE prophylaxis administered after hospital admission? / / Is there documentation why VTE prophylaxis was not administered at hospital admission? Is there physician/apn/pa documentation why Oral Factor Xa Inhibitor was administered for VTE prophylaxis? Stroke form -NOT FOR USE WITHOUT PERMISSION. 2014 American Heart Association and Quintiles. Page 6

Other Therapeutic Anticoagulati on Unfractionated heparin IV Dabigatran (Pradaxa) Argatroban Desirudin (Iprivask) Rivaroxaban (Xarelto) Apixaban (Eliquis) Lepirudin (Refludan) Other Anticoagulant Was DVT or PE documented? /ND Was antithrombotic therapy administered by the end of hospital day 2? /ND Ο NC If yes, select all that apply Antiplatelet Anticoagulant Is there documentation by a physician/advanced practice nurse/physician assistant (physician/apn/pa) or pharmacist in the medical record of a reason for not administering antithrombotic therapy by end of hospital day 2? MEASUREMENTS Total Lipids: ND Triglycerides: HDL: mg/dl LDL: Chol: mg/dl mg/dl mg/dl Lipids: NC A 1 C: Blood Glucose A % 1 C: ND (required if patient received IV tpa): mg/dl Too Low Too High Serum ^What is the first platelet count obtained prior to or after Creatinine: hospital arrival? UTD INR: NC ^Is there documentation in the medical record that the INR value performed closest to hospital arrival was greater than 1.4? ^^If initial INR > 1.4 and treated with procoagulant, Date/Time first INR 1.4 after treatment: No documented INR 1.4 after tx Vital Signs: Height: Weight: Heart Rate (beats per minute): Blood Pressure (required if patient received IV tpa): / mmhg (Systolic/Diastolic) Ο in Ο cm Ο lbs Ο kg Waist Circumference: Ο in Ο cm BMI: DISCHARGE INFORMATION Discharge Date/Time: GWTG Ischemic Stroke-Only Estimated Mortality Rate [Calculated in the PMT] GWTG Global Stroke Estimated Mortality Rate (Ischemic Stroke, SAH, ICH, Stroke NOS) [Calculated in the PMT] Modified Rankin Scale at Discharge /ND If Yes: Ο Actual Ο Estimated from the record Ο ND Total Score (refer to web program for questions) Ambulatory status at discharge Discharge Blood Pressure (Measurement closest to discharge) DISCHARGE DIAGNOSIS ICD-9 Other Diagnosis Codes Ο Able to ambulate independently (no help from another person) w/ or w/o device Ο With assistance (from person) Ο Unable to ambulate Ο ND / mmhg(systolic/diastolic). No Stroke or TIA Related ICD-9 Code Present DISCHARGE TREATMENTS Antithrombotic Therapy Prescribed? /ND Ο NC Discharge Tab Stroke form -NOT FOR USE WITHOUT PERMISSION. 2014 American Heart Association and Quintiles. Page 7

approved in stroke Stroke Patient Management Tool (Standard, CM, Comprehensive) December 2014 If yes, Antiplatelet aspirin aspirin/dipyridamole (Aggrenox) clopidogrel (Plavix) ticlopidine (Ticlid) Dosage 1. 2. 3 4. If NC, documented contraindications Frequency 1. 2. 3 4. Anticoagulant Unfractionated heparin IV full dose LMW heparin warfarin (Coumadin) dabigatran (Pradaxa) argatroban fondaparinux (Arixtra) rivaroxaban (Xarelto) apixaban (Eliquis) lepirudin (Refludan) Dosage 1. 2. 3 4. Allergy to or complications r/t antithrombotic Patient/Family refused Risk for bleeding or discontinued due to bleeding Frequency 1. 2. 3 4. Serious side effect to medication Terminal illness/comfort Measures Only Other Prescribed? If yes, Other Antithrombotic(s) Medication: Dosage: Frequency: desirudin (Iprivask) 1. 1. ticagrelor (Brilinta) 2. 2. *contraindication in stroke and TIA prasugrel (Effient) 3 3. Other 4. 4. Persistent or Paroxysmal Atrial Fibrillation/Flutter If atrial fib/flutter or history of PAF documented, was patient discharged on anticoagulation? /ND Ο NC Allergy to or complication r/t warfarin or heparins Risk for falls If NC, documented reasons for Mental status Serious side effect to medication no anticoagulation Patient refused Terminal illness/comfort Measures Only Risk for bleeding or discontinued due to bleeding Antihypertensive Tx (Select all that apply) Cholesterol-Reducing Tx Statin Medication: (see Coding Key) None prescribed/nd None - contraindicated None prescribed/nd None - contraindicated ACE Inhibitors ARB Statin Fibrate Beta Blockers Ca++ Channel Blockers Niacin Absorption Inhibitor Diuretics Other anti-hypertensive med Other med Statin Total Daily Dose: Documented reason for not prescribing a statin medication at discharge? Intensive Statin Therapy /ND Ο NC New Diagnosis of Diabetes? Ο ND Basis for Diagnosis (Select all that apply): HbA1c Oral Glucose Tolerance Fasting Blood Sugar Test Other Stroke form -NOT FOR USE WITHOUT PERMISSION. 2014 American Heart Association and Quintiles. Page 8

Diabetic Tx (Select all that apply): None prescribed/nd None contraindicated Other subcutaneous/injectable agents Anti-Smoking Tx /ND Ο NC Was the patient prescribed any antidepressant class of, SSRI, any other antidepressant class /ND medication at discharge? OTHER LIFESTYLE INTERVENTIONS Reducing weight and/or increasing activity recommendations /ND Ο NC TLC Diet or Equivalent /ND Ο NC Antihypertensive Diet /ND Ο NC Was Diabetes Teaching Provided? /ND Ο NC Insulin Oral agents STROKE EDUCATION Patient and/or caregiver received education and/or resource materials regarding all of the following: Check all as Yes: Stroke Warning Signs and Risk Factors for Stroke Symptoms How to Activate EMS for Stroke Need for Follow-Up After Discharge Their Prescribed Medication STROKE REHABILITATION Patient assessed for and/or received rehabilitation services during this hospitalization? Check all rehab services that patient received or was assessed for: POST DISCHARGE Patient received rehabilitation services during hospitalization Patient transferred to rehabilitation facility Patient referred to rehabilitation services following discharge Patient ineligible to receive rehabilitation services because symptoms resolved Patient ineligible to receive rehabilitation services due to impairment (i.e. poor prognosis, patient unable to tolerate rehabilitation therapeutic regimen) Go to Post Discharge Follow-Up Form within online tool (refer to web program for questions) ^What is the patients Modified Rankin Score (mrs) at 90 days post discharge? ^What is the date that the Modified Rankin Score (mrs) was obtained post discharge? / / OPTIONAL FIELDS Please do not enter any patient identifiers in this section Field 1 Field 2 Field 3 Field 4 Field 5 Field 6 Field 7 Field 8 Field 9 Field 10 Field 11 Field 12 Field 13 Additional Comments Field 14 Optional Fields Tab Administrative PMT used concurrently or retrospectively or combination? Ο Concurrently Ο Retrospectively Ο Combination Was a stroke admission order set used in this patient? Was a stroke discharge checklist used in this patient? Patient adherence contract/compact used? CORE MEASURE TAB (many elements are auto-populated within the online PMT) Core Measures Tab Check if patient is part of a sample First Name Last Name Stroke form -NOT FOR USE WITHOUT PERMISSION. 2014 American Heart Association and Quintiles. Page 9

Race Stroke Patient Management Tool (Standard, CM, Comprehensive) December 2014 Ο Black or African American Ο American Indian or Alaska Native Zip Code - Homeless ΟAsia n Ο White Ο Native Hawaiian or Pacific Islander Ο UTD What is the patient's source of payment for this episode of care? Ο Medicare n-medicare HIC Number Was history of atrial fibrillation/flutter or current finding of atrial fibrillation/flutter documented in the medical record? Is there documentation that the patient was on a lipid-lowering medication prior to hospital arrival? Is there documentation that the date and time of last known well was witnessed or reported? What was the date and time at which the patient was last known to be well or at his or her baseline state of health? When is the earliest physician/apn/pa documentation of comfort measures only? Ο Day 0 or 1 Ο Day 2 or after Ο Timing unclear t Documented/UTD IV thrombolytic therapy initiated at this hospital? Did the patient receive IV or IA thrombolytic (t-pa) therapy at this hospital or within 24 hours prior to arrival? Documented reasons for not initiating IV thrombolytic? Was antithrombotic therapy administered by the end of hospital day 2? Was the LDL-cholesterol (LDL-c) measured within the first 48 hours or 30 days prior to hospital arrival? Was the patient's highest LDL-cholesterol (LDL-c) level greater than or equal to 100 mg/dl in the first 48 hours or within 30 days prior to hospital arrival? Discharge Date/Time Was antithrombotic therapy prescribed at hospital discharge? Is there documentation by a physician/advanced practice nurse/physician assistant (physician/apn/pa) or pharmacist in the medical record of a reason for not prescribing antithrombotic therapy at hospital discharge? Was anticoagulation therapy prescribed at hospital discharge? Is there documentation by a physician/advanced practice nurse/physician assistant (physician/apn/pa) or pharmacist in the medical record of a reason for not prescribing anticoagulation therapy at hospital discharge? Was a statin medication prescribed at discharge? Stroke Core Measure Additional Comments Stroke form -NOT FOR USE WITHOUT PERMISSION. 2014 American Heart Association and Quintiles. Page 10