Specifications Manual for National Inpatient Hospital Quality Reporting Measures

Specifications Manual for National Inpatient Hospital Quality Reporting Measures Release Notes Version: 4.4 Release Notes Completed: June 11, 2014 Guidelines for Using Release Notes Release Notes 4.4 provide modifications to the Specifications Manual for National Hospital Inpatient Quality Measures. The Release Notes are provided as a reference tool and are not intended to be used to program abstraction tools. Please refer to the Specifications Manual for National Hospital Inpatient Quality Measures for the complete and current technical specifications and abstraction information. The notes are organized to follow the order of the Table of Contents. The implementation date is 01-01-2015, unless otherwise specified. The headings are described below: Impacts - used to identify the impacted measures and portion(s) of the Manual Section. (i.e., Alphabetical Data Dictionary, Measure Information Form (MIF) and Flowchart (Algorithm)). Description of Changes - used to identify the section within the document where the change occurs, e.g., Definition, Data Collection Question, Allowable Values, and Denominator Statement - Data Elements. Rationale - provided for the change being made. Data elements that cross multiple measures and contain the same changes will be consolidated.

Table of Contents Note: click on any section title in the Release Notes to return to Table of Contents page Table of Contents... 2 Acknowledgement... 3 Introduction... 3 Using the Specifications Manual for National Hospital Inpatient Quality Measures... 4 SECTION 1 Data Dictionary... 5 Introduction to Data Dictionary... 5 Alphabetical Data Dictionary... 5 Index Updates... 5 Deleted Data Elements... 8 Data Element Updates... 9 SECTION 2 Measurement Information... 65 Subsection 2.1 Acute Myocardial Infarction (AMI)... 66 Subsection 2.2 Heart Failure (HF)... 71 Subsection 2.3 Pneumonia (PN)... 72 Subsection 2.4 Surgical Care Improvement Project (SCIP)... 74 Subsection 2.6 Children s Asthma Care (CAC)... 78 Subsection 2.7 Venous Thromboembolism (VTE)... 79 Subsection 2.8 Stroke (STK)... 81 Subsection 2.9 Global Initial Patient Population (ED, IMM, TOB, SUB)... 85 Subsection 2.10 - Emergency Department (ED)... 85 Subsection 2.11.1 - Immunization (IMM)... 87 Subsection 2.11.2 - Tobacco Treatment (TOB)... 87 Subsection 2.11.3 - Substance Use (SUB)... 90 SECTION 3 Missing and Invalid Data... 93 SECTION 4 Population and Sampling Specifications... 93 SECTION 9 Data Transmission... 94 Transmission Alphabetical Data Dictionary... 95 Hospital Clinical Data XML File Layout... 95 Hospital Initial Patient Population Data XML File Layout... 108 SECTION 10 CMS Outcome Measures (Claims Based)... 108 Subsection 10.1 Introduction Risk Standardized Mortality Measures... 108 Subsection 10.2 Introduction Risk Standardized Readmission and Complication Measures... 108 Subsection 10.3 Agency for Healthcare Research and Quality (AHRQ) Measures... 109 Subsection 10.4 Healthcare Associated Infections (HAI) Measures... 109 Subsection 10.5 CMS Payment Measures... 109 Subsection 10.6 Structural Measures... 110 APPENDICES... 110 Appendix A ICD-9-CM Code Tables... 110 Appendix C Medication Tables... 112 Appendix D Glossary of Terms... 114 Appendix E Overview of Measure Information Form and Flowchart Formats... 114 Appendix F Measure Name Crosswalk... 114 Appendix G Resources... 114 Appendix H Miscellaneous Tables... 115 Appendix P Preview Section... 115 Specifications Manual for Hospital Inpatient Quality Measures Page 1

The notes in the tables below are organized to follow the Table of Contents in the specifications manual. Table of Contents Section 2 Measurement Information Rationale: These measures are being removed based on the FY 2014 IPPS Final Rule and at the direction of CMS. 2.1 Acute Myocardial Infarction (AMI) Remove: AMI-2 AMI-10 2.2 Heart Failure (HF) Remove: HF-1 HF-3 Section 2 Measurement Information Rationale: The PN-3a and PN-3b measures are being removed at the direction of CMS and based on the IPPS Fiscal Year 2014 Final Rule. 2.3 Pneumonia (PN) Measure Information Form (MIF) and Flowchart (Algorithm) Remove: PN-3a, PN-3b Section 2 Measurement Information Rationale: The Hospital IQR Program Measure, Surgery Patients with Perioperative Temperature Management, was removed in the IPPS Fiscal Year 2014 Final Rule. 2.4 Surgical Care Improvement Project (SCIP) Measure Information Form (MIF) and Flowchart (Algorithm) Remove: SCIP-Inf-10 Specifications Manual for Hospital Inpatient Quality Measures Page 2

Section 2 Measurement Information Rationale: The measure specifications for AMI-2, AMI-10, HF-3, and PN-3a have been removed from the Specifications Manual for National Hospital Inpatient Quality Measures and placed in the Specifications Manual for Joint Commission National Quality Core Measures. Add at the bottom of last page of Table of Contents: Additional comments The measure specifications for AMI-2, AMI-10, HF-3, and PN-3a have been removed from the Specifications Manual for National Hospital Inpatient Quality Measures effective 01/01/2015, however, these will continue to be used by The Joint Commission and are available in the Specifications Manual for Joint Commission National Quality Core Measures which is located on The Joint Commission s website at the following link: http://manual.jointcommission.org/bin/view/manual. 10.5 CMS AMI Episode-of-Care Payment Measure Rationale: The section name is being revised to reflect all payment measures. In addition, a new payment measure is being added. Change section name from: 10.5 CMS AMI Episode-of-Care Payment Measure To 10.5 CMS Payment Measures Add new measure: MSPB-1: Medicare Spending Per Beneficiary (MSPB) Acknowledgement No updates in this section. Introduction No updates in this section. Specifications Manual for Hospital Inpatient Quality Measures Page 3

Using the Specifications Manual for National Hospital Inpatient Quality Measures Not Applicable (N/A) Rationale: The HF-1 measure is being removed based on the FY 2014 IPPS Final Rule and at the direction of CMS. Example needs changed in Measurement Information sub-section. Section 2 - Measurement Information Change third sentence in first paragraph to: For example, in the Stroke (STK) measure set, the measure that addresses STK patients receiving VTE prophylaxis is listed as: STK-1 and measure short name: Venous Thromboembolism (VTE) Prophylaxis. N/A Rationale: This section is being updated to provide information on included measures. Section 10 CMS Outcome Measures (Claims Based) Change first sentence in first paragraph to: This section of the manual provides an overview and the Measure Information Forms for the CMS mortality, readmission and complication measures, as well as the AMI episode of care payment measure. Change second sentence in first paragraph to: In addition, this section provides a link to the development and technical specifications for the Agency for Healthcare Research and Quality (AHRQ) Claims-Based Quality Measures. Add second paragraph: The structural measures are listed in this section also, although they are not claim-based. Data entry for the structural measures is achieved through the secure side of QualityNet via an online tool available to authorized users. N/A Rationale: This change is to clarify for abstractors what measures in the specifications manual are considered chart-abstracted measures. Section 2 - Measurement Information Add paragraphs: Measures listed in this section are known as Chart-Abstracted Measures. Chart abstraction is the review of medical record documentation from the current episode of care for purposes of data collection and submission. In addition, measures in this section which are eligible for voluntary electronic submission as emeasures for the Hospital Inpatient Quality Reporting (IQR) program are identified in the specific Measure Information Form(s). Specifications Manual for Hospital Inpatient Quality Measures Page 4

Section 10 CMS Outcome Measures (Claims Based) Add paragraph: The Inpatient Web-based Measure in this section is known as a Chart-Abstracted Measure as described in Section 2- Measurement Information. In addition, the measure is eligible for voluntary electronic submission as an emeasure for the Hospital IQR program as identified in the specific Measure Information Form. SECTION 1 Data Dictionary Introduction to Data Dictionary General Abstraction Guidelines Rationale: The verbiage used in the manual is being updated to reflect new guidance from the IPPS Final Rule. Medical Record Documentation Change seventh paragraph to: Please note that hospitals that are selected for validation will need to provide a paper or electronic (i.e., CD, DVD, or thumb drive) copy of the current medical record in its entirety, including all previous testing or history documents used in abstraction. If a hospital uses electronic data for abstraction and is unable to provide a paper or electronic copy of these data, and the record is chosen for validation, there is the potential for a mismatch to occur. Alphabetical Data Dictionary Index Updates Alphabetical Data Dictionary Index Rationale: The current measure specifications exclude patients with cognitive impairment from all of the TOB and SUB measures, if there is documentation of cognitive impairment for the entire hospitalization. Since the alcohol use screen and/or tobacco use screen must be completed within 3 days after admission, cognitive impairment will now be evaluated in the Alcohol Use Status and Tobacco Use Status data elements, and the data element Cognitive Impairment will be removed from all of the TOB and SUB measures. Alcohol Use Status Change under Collected For column to: All SUB Measures Remove Cognitive Impairment row Tobacco Use Status Change under Collected For column to: All TOB Measures Specifications Manual for Hospital Inpatient Quality Measures Page 5

Alphabetical Data Dictionary Index Rationale: The Hospital IQR Program Measure, Surgery Patients with Perioperative Temperature Management, was removed in the IPPS Fiscal Year 2014 Final Rule. Anesthesia End Date Anesthesia End Time Anesthesia Start Date Anesthesia Start Time Remove under Collected For column: SCIP-Inf-10 Alphabetical Data Dictionary Index Rationale: The Hospital IQR Program Measure, Surgery Patients with Perioperative Temperature Management, was removed in the IPPS Fiscal Year 2014 Final Rule. Remove rows in their entirety: Anesthesia Type Intentional Hypothermia Temperature Alphabetical Data Dictionary Index Antibiotic Administration Date Antibiotic Administration Route Antibiotic Administration Time Antibiotic Name Antibiotic Received Arrival Date Arrival Time Chest X-Ray Clinical Trial Comfort Measures Only Discharge Disposition ICU Admission or Transfer Pneumonia Diagnosis: ED/Direct Admit Transfer From Another Hospital or ASC Rationale: The PN-3a and PN-3b measures are being removed at the direction of CMS and based on the IPPS Fiscal Year 2014 Final Rule. Remove under Collected For column: PN-3a PN-3b Specifications Manual for Hospital Inpatient Quality Measures Page 6

Alphabetical Data Dictionary Index Rationale: These measures are being removed based on the FY 2014 IPPS Final Rule and at the direction of CMS. Remove rows in their entirety: Aspirin Prescribed at Discharge Discharge Instructions Address Activity Discharge Instructions Address Diet Discharge Instructions Address Follow-up Discharge Instructions Address Medications Discharge Instructions Address Symptoms Worsening Discharge Instructions Address Weight Monitoring LDL-c Less Than 100 mg/dl Reason for No Aspirin at Discharge Remove under Collected For column: AMI-2 AMI-10 HF-1 HF-3 Clinical Trial Comfort Measures Only Remove in the Collected For column: All HF Measures Add in the Collected For column: HF-2 Clinical Trial Remove in the Collected For column: AMI-1 AMI-3 AMI-5 AMI-7 AMI-7a AMI-8 AMI-8a Add in the Collected For column: All AMI Measures Alphabetical Data Dictionary Index Rationale: The PN-3a and PN-3b measures are being removed at the direction of CMS and based on the IPPS Fiscal Year 2014 Final Rule. Remove under Collected For column: Specifications Manual for Hospital Inpatient Quality Measures Page 7

PN-3a PN-3b Remove rows in their entirety: Blood Culture Collected Initial Blood Culture Collection Date Initial Blood Culture Collection Time Alphabetical Data Dictionary Index Element Name Reason for Discontinuation of Parenteral Therapy Rationale: Clinical scenarios presented to the Technical Advisory Panel (TAP) justified the need for defined time frames, and the need for examples and clarifications to capture acceptable documentation for these data elements. Change Element Name to: Reason for Discontinuation of Parenteral Anticoagulation Therapy Alphabetical Data Dictionary Index Rationale: This change is to adjust the measure flow logic and add a new data element that will exclude cases who received IV thrombolytic therapy in 3 to 4.5 hours because a reason delayed initiation within 3 hours. Add row under Element Name and Collected For column respectively: Reason for Extending the Initiation of IV Thrombolytic STK-4 Alphabetical Data Dictionary Index Rationale: The Technical Advisory Panel reviewed clinical scenarios presented and determined that a timeframe was needed for documentation to be acceptable for these data elements. An additional data element was added to further define reasons for not providing prophylaxis to records in VTE-6 Hospital Acquired VTE. Add row under Element Name and Collected For column respectively: Reason for No Administration of VTE Prophylaxis VTE-6 Deleted Data Elements Data Elements Rationale: The Hospital IQR Program Measure, Surgery Patients with Perioperative Temperature Management, was removed in the IPPS Fiscal Year 2014 Final Rule. Specifications Manual for Hospital Inpatient Quality Measures Page 8

Remove in their entirety: Anesthesia Type Intentional Hypothermia Temperature Data Elements Rationale: These measures are being removed based on the FY 2014 IPPS Final Rule and at the direction of CMS. Remove data elements in their entirety: Aspirin Prescribed at Discharge Discharge Instructions Address Activity Discharge Instructions Address Diet Discharge Instructions Address Follow up Discharge Instructions Address Medications Discharge Instructions Address Symptoms Worsening Discharge Instructions Address Weight Monitoring LDL c Less Than 100 mg/dl Reason for No Aspirin at Discharge Data Element Updates ACEI Prescribed at Discharge ARB Prescribed at Discharge LVSD Reason for No ACEI and No ARB at Discharge Rationale: These measures are being removed based on the FY 2014 IPPS Final Rule and at the direction of CMS. Collected For The Joint Commission Only: AMI-3; CMS Voluntary Only: AMI-3 Admission Date Rationale: The verbiage used in the manual for data elements collected for all records is being updated. Notes for Abstraction Remove in second bullet, first sub-bullet: Specifications Manual for Hospital Inpatient Quality Measures Page 9

(Form Locator 12) Remove in second bullet, second sub-bullet: in Form Locator 6 ONLY ALLOWABLE SOURCES Change the third listing to: 3. UB-04 Excluded Data Sources UB-04, From and Through dates Alcohol Use Status Rationale: The current measure specifications exclude patients with cognitive impairment from all of the TOB and SUB measures, if there is documentation of cognitive impairment for the entire hospitalization. Since the alcohol use screen and/or tobacco use screen must be completed within 3 days after admission, cognitive impairment will now be evaluated in the Alcohol Use Status and Tobacco Use Status data elements, and the data element Cognitive Impairment will be removed from all of the TOB and SUB measures. Change: Collected For The Joint Commission Only: All SUB Measures; CMS Informational Only: All SUB Measures Allowable Values Add new value: 7 The patient was not screened for alcohol use during the first three days of admission because of cognitve impairment. Notes for Abstraction Add new bullets and examples: Cognition refers to mental activities associated with thinking, learning, and memory. Cognitive impairment for the purposes of this measure set is related to documentation that the patient cannot be screened for alcohol use due to the impairment (e.g., comatose, obtunded, confused, memory loss) during the entire first three days of hospitalization. Cognitive impairment must be documented at all times during the first three days of the hospitalization in order to select value 7. If there is documentation in the medical record that a patient is cognitively impaired, and there is no additional documentation that the patient s mental status was normal at any other time during the first three days of the hospitalization, i.e., alert and oriented the abstractor can select value 7. If there is documentation that the patient has temporary cognitive impairment due to acute substance use (e.g., overdose or acute intoxication) value 7 cannot be selected. Examples of cognitive impairment include: Specifications Manual for Hospital Inpatient Quality Measures Page 10

o Altered Level of Consciousness (LOC) o Altered Mental Status o Cognitive impairment o Cognitively impaired o Confused o Memory loss o Mentally retarded o Obtunded Anesthesia End Date Anesthesia End Time Anesthesia Start Date Anesthesia Start Time Rationale: The Hospital IQR Program Measure, Surgery Patients with Perioperative Temperature Management, was removed in the IPPS Fiscal Year 2014 Final Rule. Anesthesia End Date Anesthesia End Time Anesthesia Start Time Remove under Collected For : CMS Voluntary Only: SCIP-Inf-10 Anesthesia Start Date Remove under CMS Voluntary Only : SCIP-Inf-10 Antibiotic Administration Date Antibiotic Administration Route Antibiotic Administration Time Antibiotic Name Antibiotic Received Rationale: The PN-3a and PN-3b measures are being removed at the direction of CMS and based on the IPPS Fiscal Year 2014 Final Rule. Collected For Remove: CMS Voluntary Only: PN-3b Arrival Date Arrival Time Clinical Trial Comfort Measures Only Specifications Manual for Hospital Inpatient Quality Measures Page 11

Rationale: The PN-3a and PN-3b measures are being removed at the direction of CMS and based on the IPPS Fiscal Year 2014 Final Rule. Collected For Remove under The Joint Commission Only : PN-3a Remove under CMS Voluntary Only : PN-3a, PN-3b Assessed for Rehabilitation Services Rationale: This change is to clarify which providers should be considered members of the rehabilitation team. Notes for Abstraction Change first bullet to: The assessment for rehabilitation services must be completed by a qualified provider. See the inclusion list. Suggested Data Sources PHYSICIAN/APN/PA/KT/PT/OT/SLT OR NEUROPSYCHOLOGIST DOCUMENTATION ONLY FOR REHABILITATION ASSESSMENT: Consultation notes Discharge summary History and physical Progress notes Referral forms Rehabilitation records Therapy notes (e.g., KT/PT/OT/SLT) Excluded Data Sources Add: Any documentation other than Physician/APN/PA/KT/PT/OT/SLT/Neuropsychologist Remove: Nursing assessments for activities of daily living (ADLs). Nursing notes Inclusion Guidelines for Abstraction Change second bullet to: Patient received rehabilitation services from a member of the rehabilitation team. Change third bullet with sub-bullets to: Members of the rehabilitation team: o Advanced Practice Nurse (APN) Specifications Manual for Hospital Inpatient Quality Measures Page 12

o Kinesiotherapist (KT) o Neuro-psychologist (PsychD) o Occupational therapist (OT) o Physical therapist (PT) o Physician o Physician Assistant (PA) o Speech and language pathologist (SLT) Atrial Fibrillation/Flutter Rationale: This change is to provide abstractor clarification for cases with questionable atrial fibrillation/flutter and/or conflicting documentation. Definition Documentation by a physician/apn/pa that the patient has a history of ANY atrial fibrillation (e.g., remote, persistent, or paroxysmal) or atrial flutter OR a diagnosis or signed ECG tracing of ANY atrial fibrillation or flutter. Suggested Data Collection Question: Was there physician/apn/pa documentation of a diagnosis, signed ECG tracing, or a history of ANY atrial fibrillation/flutter in the medical record? Allowable Values: Change from: Y (Yes) History of any atrial fibrillation/flutter or current finding of atrial fibrillation/flutter was documented. To: N (No) Y (Yes) N (No) History of any atrial fibrillation/flutter or current finding of atrial fibrillation/flutter was not documented, OR unable to determine from medical record documentation. There is physician/apn/pa documentation of a diagnosis or a history of ANY atrial fibrillation/flutter. There is no physician/apn/pa documentation of a diagnosis or a history of ANY atrial fibrillation/flutter, OR unable to determine from medical record documentation. Notes for Abstraction If there is a documented history or diagnosis of ANY condition (e.g., remote, persistent, or paroxysmal) described in the definition statement, select Yes. If there is documentation of atrial fibrillation or flutter on a signed ECG, select Yes. Specifications Manual for Hospital Inpatient Quality Measures Page 13

If there is a diagnosis of atrial fibrillation or flutter anywhere in the medical record, or documentation of a past history of atrial fibrillation or flutter anywhere in the medical record, select Yes. EXCEPTION: If there is conflicting documentation of atrial fibrillation or flutter during the hospitalization, the most current cardiologist documentation should be used. If cardiology documentation is unavailable, the most current documentation by other physician/apn/pa should be used. If there is physician/apn/pa documentation of any of the following examples, disregard and continue to review the medical record for a confirmed diagnosis. If no other documentation exists, select No. o suspected/suspicion of atrial fibrillation or flutter o rule out atrial fibrillation/flutter o questionable atrial fibrillation/flutter o possible atrial fibrillation/flutter If there is documentation of a history of an ablation procedure for atrial fibrillation/flutter, select Yes. If there is documentation of a history of atrial fibrillation or flutter that terminated within 8 weeks following CABG, select No. If there is documentation of a history of transient and entirely reversible episode of atrial fibrillation or flutter due to thyrotoxicosis, select No. Suggested Data Sources Suggested Data Sources: PHYSICIAN/APN/PA DOCUMENTATION ONLY Discharge instruction sheet Discharge summary History and physical ECG report Holter monitor report Problem list Progress Notes Transfer sheet Inclusion Guidelines for Abstraction None Exclusion Guidelines for Abstraction PAC Paroxysmal atrial tachycardia Paroxysmal supraventricular tachycardia PAT Premature atrial contraction PST Specifications Manual for Hospital Inpatient Quality Measures Page 14

Birthdate Rationale: The verbiage used in the manual for data elements collected for all records is being updated. Suggested Data Sources Change last bullet to: UB-04 Blood Culture Collected Initial Blood Culture Collection Date Initial Blood Culture Collection Time Rationale: The PN-3a and PN-3b measures are being removed at the direction of CMS and based on the IPPS Fiscal Year 2014 Final Rule. Remove data elements in their entirety. Chest X-Ray Pneumonia Diagnosis: ED/Direct Admit Rationale: The PN-3a and PN-3b measures are being removed at the direction of CMS and based on the IPPS Fiscal Year 2014 Final Rule. Collected For Remove under The Joint Commission Only : PN-3a Remove: CMS Voluntary Only: PN-3a, PN-3b Clinical Trial Comfort Measures Only Discharge Disposition Rationale: These measures are being removed based on the FY 2014 IPPS Final Rule and at the direction of CMS. Collected For Remove under The Joint Commission Only : AMI-2, AMI-10, HF-3 Remove under CMS Voluntary Only : Specifications Manual for Hospital Inpatient Quality Measures Page 15

AMI-2, AMI-10, HF-1, HF-3 Cognitive Impairment Rationale: The current measure specifications exclude patients with cognitive impairment from all of the TOB and SUB measures, if there is documentation of cognitive impairment for the entire hospitalization. Since the alcohol use screen and/or tobacco use screen must be completed within 3 days after admission, cognitive impairment will now be evaluated in the Alcohol Use Status and Tobacco Use Status data elements, and the data element Cognitive Impairment will be removed from all of the TOB and SUB measures. Remove Cognitive Impairment data element in its entirety Comfort Measures Only Rationale: These changes will provide clarification to the abstractor and make the data element more consistent with the applicable measures. Notes for Abstraction Only accept terms identified in the list of inclusions. No other terminology will be accepted. Physician/APN/PA documentation of comfort measures only (hospice, comfort care, etc.) mentioned in the following contexts suffices: o Comfort measures only recommendation o Order for consultation or evaluation by a hospice care service o Patient or family request for comfort measures only o Plan for comfort measures only o Referral to hospice care service o Discussion of comfort measures Determine the earliest day comfort measures only (CMO) was DOCUMENTED by the physician/apn/pa. If any of the inclusion terms are documented by the physician/apn/pa, select value 1, 2, or 3 accordingly. Example: Discussed comfort care with family on arrival noted in day 2 progress note Select 2. State Authorized Portable Orders (SAPOs): o SAPOs are specialized forms or identifiers authorized by state law that translate a patient s preferences about specific end-of-life treatment decisions into portable medical orders. Examples: DNR-Comfort Care form MOLST (Medical Orders for Life-Sustaining Treatment) POLST (Physician Orders for Life-Sustaining Treatment) Out-of-Hospital DNR (OOH DNR) Specifications Manual for Hospital Inpatient Quality Measures Page 16

o If there is a SAPO in the record that is dated and signed prior to arrival with an option in which an inclusion term is found that is checked, select value 1. o If a SAPO lists different options for CMO and any CMO option is checked, select value 1, 2, or 3 as applicable. o If one or more dated SAPOs are included in the record (and signed by the physician/apn/pa), use only the most recent one. Disregard undated SAPOs. o For cases where there is a SAPO in the record with a CMO option selected: If the SAPO is dated prior to arrival and there is documentation on the day of arrival or the day after arrival that the patient does not want CMO, and there is no other documentation regarding CMO found in the record, disregard the SAPO. Example: Patient has a POLST dated prior to arrival in his chart and ED physician states in current record Patient is refusing comfort measures, wants to receive full treatment and be a full code. Documentation of an inclusion term in the following situations should be disregarded. Continue to review the remaining physician/apn/pa documentation for acceptable inclusion terms. If the ONLY documentation found is an inclusion term in the following situations, select value 4. o Documentation (other than SAPOs) that is dated prior to arrival or documentation which refers to the pre-arrival time period. Examples: Comfort measures only order in previous hospitalization record. Pt. on hospice at home in MD ED note. o Inclusion term clearly described as negative or conditional. Examples: No comfort care" "Not appropriate for hospice care" Comfort care would also be reasonable - defer decision for now DNRCCA (Do Not Resuscitate Comfort Care Arrest) Family requests comfort measures only should the patient arrest. o Documentation of CMO should be disregarded if documentation makes clear it is not being used as an acronym for Comfort Measures Only (e.g., hx dilated CMO Cardiomyopathy context). If there is physician/apn/pa documentation of an inclusion term in one source that indicates the patient is Comfort Measures Only, AND there is physician/apn/pa documentation of an inclusion term in another source that indicates the patient is NOT CMO, the source that indicates the patient is CMO would be used to select value 1, 2, or 3 for this data element. Examples: o o Physician documents in progress note on day 1 The patient has refused Comfort Measures AND then on day 2 the physician writes an order for a Hospice referral. Select value 2. ED physician documents in a note on day of arrival Patient states they want to be enrolled in Hospice AND then on day 2 there is a physician progress note with documentation of Patient is not a Hospice candidate. Select value 1. Suggested Data Sources: Remove: IN THE FOLLOWING ONLY ACCEPTABLE SOURCES: Specifications Manual for Hospital Inpatient Quality Measures Page 17

Add new first bullet: Consultation notes Add new fifth bullet: History and physical Inclusion Guidelines for Abstraction Add new bullet: Terminal extubation Date Last Known Well Rationale: This change is to clarify the abstraction guidelines for data elements that generate the majority of stroke abstraction questions and ease the burden of abstraction. Suggested Data Collection Question What was the date associated with the time at which the patient was last known to be well or at his or her baseline state of health? Notes for Abstraction Enter the date associated with the Time Last Known Well. If the date last known well is unable to be determined from medical record documentation, enter UTD. The medical record must be abstracted as documented (taken at face value ). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD. Example: Documentation indicates the Date Last Known Well was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the Date Last Known Well is outside of the range listed in the Allowable Values for Day, it is not a valid date and the abstractor should select UTD. Note: Transmission of a case with an invalid date as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission s Data Warehouse. Use of UTD for Date Last Known Well allows the case to be accepted into the warehouse. If the date last known well is documented as a specific date and entered as Date Last Known Well on a Code Stroke form or stroke-specific electronic template, enter that date as the date last known well. Documentation of Date Last Known Well on a strokespecific form or template should be selected regardless of other dates last known well documented elsewhere in the medical record. References in relation to Arrival Date are acceptable (e.g., today, tonight, this evening, and this morning). The Date Last Known Well and the Arrival Date may be the same date or a different date. Examples: o Wife reports patient normal this evening until approximately 9 PM. Hospital arrival is 0030 on 12-10-20xx. Date Last Known Well is 12-09-20xx. Specifications Manual for Hospital Inpatient Quality Measures Page 18

o Patient states he felt perfectly fine earlier today. At noon, he began to have trouble seeing. Hospital arrival is 3:59 PM on 12-10-20xx. Date Last Known Well is 12-10-20xx. If a reference to date last known well is documented without a specific date, enter that date for the Date Last Known Well. If multiple dates are documented, select the earliest date. Examples: o Patient last known well today (day of arrival). Select Arrival Date for Date Last Known Well. o Patient normal yesterday (day before arrival) documented in H&P and consult note documents that patient was last known to be well on Monday (two days prior to arrival). Select Monday s date for Date Last Known Well. Suggested Data Sources Add new bullet: Code Stroke form/template Inclusion Guidelines for Abstraction Signs and Symptoms of Stroke Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache Decision to Admit Date Decision to Admit Time Rationale: These changes to the Notes for Abstraction and/or the Inclusion/Exclusion guidelines are being added for clarification in abstraction, based on questions received in the QualityNet Q&A tool. Suggested Data Sources Remove: PHYSICIAN/APN/PA DOCUMENTATION ONLY Decision to Admit Date Inclusion Guidelines for Abstraction Change second bullet to: Disposition Date Discharge Date Rationale: The verbiage used in the manual for data elements collected for all records is being updated. Specifications Manual for Hospital Inpatient Quality Measures Page 19

Collected For CMS/The Joint Commission: All Records Suggested Data Sources Change last bullet to: UB-04 Discharge Disposition Rationale: The PN-3a and PN-3b measures are being removed at the direction of CMS and based on the IPPS Fiscal Year 2014 Final Rule. Collected For Remove under CMS Voluntary Only : PN-3b ED Departure Date Rationale: These changes to the Notes for Abstraction and/or the Inclusion/Exclusion guidelines are being added for clarification in abstraction, based on questions received in the QualityNet Q&A tool. Notes for Abstraction Remove fourth bullet: If there is documentation the patient left against medical advice and it cannot be determined what time the patient left against medical advice, select UTD. Exclusion Guidelines for Abstraction Patient Admission Date ED Departure Time Rationale: These changes to the Notes for Abstraction and/or the Inclusion/Exclusion guidelines are being added for clarification in abstraction, based on questions received in the QualityNet Q&A tool. Notes for Abstraction Add new seventh bullet: Do not use documentation of vital signs or medications if they are later than the ED departure time. Exclusion Guidelines for Abstraction Specifications Manual for Hospital Inpatient Quality Measures Page 20

Add second bullet: Patient Admission Time Follow-Up Contact Rationale: The current follow-up contact does not exclude patients who expire after discharge from TOB-4 and SUB-4. Directions on the appropriate allowable value to select in order to exclude the case have been added. Notes for Abstraction Add new fourth bullet: If follow-up contact was made and contact was made with a family member or other person who reports the patient expired within 30 days following discharge from the hospital, select allowable value 3. ICD-9-CM Other Diagnosis Codes Rationale: The verbiage used in the manual for data elements collected for all records is being updated. Collected For CMS/The Joint Commission: All Records Definition The other or secondary ICD-9-CM codes associated with the diagnosis for this hospitalization. Allowable Values Change from: Any valid ICD-9-CM diagnosis code. To Any valid diagnosis code as per the CMS ICD-9-CM master code table (ICD-9-CM Full and Abbreviated Code Titles): http://www.cms.gov/medicare/coding/icd9providerdiagnosticcodes/codes.html. Suggested Data Sources Change third bullet to: UB-04 Remove after third bullet: Note: Medicare will only accept codes listed in fields A-H Specifications Manual for Hospital Inpatient Quality Measures Page 21

ICD-9-CM Other Procedure Codes Rationale: The verbiage used in the manual for data elements collected for all records is being updated. Collected For CMS/The Joint Commission: All Records Definition The other or secondary ICD-9-CM codes identifying all significant procedures other than the principal procedure. Allowable Values Change from: Any valid ICD-9-CM procedure code. To Any valid procedure code as per the CMS ICD-9-CM master code table (ICD-9-CM Full and Abbreviated Code Titles): http://www.cms.gov/medicare/coding/icd9providerdiagnosticcodes/codes.html. Suggested Data Sources Change third bullet to: UB-04 Inclusion Guidelines for Abstraction None ICD-9-CM Other Procedure Dates Rationale: The verbiage used in the manual for data elements collected for all records is being updated. Suggested Data Sources Change last bullet to: UB-04 ICD-9-CM Principal Diagnosis Code Rationale: The verbiage used in the manual for data elements collected for all records is being updated. Collected For CMS/The Joint Commission: All Records Specifications Manual for Hospital Inpatient Quality Measures Page 22

Definition The ICD-9-CM diagnosis code that is primarily responsible for the admission of the patient to the hospital for care during this hospitalization. Allowable Values Change from: Any valid ICD-9-CM diagnosis code To Any valid diagnosis code as per the CMS ICD-9-CM master code table (ICD-9-CM Full and Abbreviated Code Titles): http://www.cms.gov/medicare/coding/icd9providerdiagnosticcodes/codes.html. Suggested Data Sources Change third bullet to: UB-04 Inclusion Guidelines for Abstraction None Exclusion Guidelines for Abstraction None ICD-9-CM Principal Procedure Code Rationale: The verbiage used in the manual for data elements collected for all records is being updated. Collected For CMS/The Joint Commission: All Records Definition The principal procedure is the procedure performed to definitive treatment rather than diagnostic or exploratory purposes or which is necessary to take care of the complication. Allowable Values Change from: Any valid ICD-9-CM procedure code. To Any valid procedure code as per the CMS ICD-9-CM master code table (ICD-9-CM Full and Abbreviated Code Titles): http://www.cms.gov/medicare/coding/icd9providerdiagnosticcodes/codes.html. Notes for Abstraction Specifications Manual for Hospital Inpatient Quality Measures Page 23

None Suggested Data Sources Change third bullet to: UB-04 Inclusion Guidelines for Abstraction None ICD-9-CM Principal Procedure Date Rationale: The verbiage used in the manual for data elements collected for all records is being updated. Suggested Data Sources Change last bullet to: UB-04 ICU Admission or Transfer Rationale: The PN-3a and PN-3b measures are being removed at the direction of CMS and based on the IPPS Fiscal Year 2014 Final Rule. Collected For Remove under The Joint Commission Only : PN-3a Remove: CMS Voluntary Only: PN-3a ICU VTE Prophylaxis Rationale: The need for clarification of documentation that is acceptable for these data elements was identified through review of clinical scenarios by the Technical Advisory Panel. Definition Remove the word initially Suggested Data Collection Question Remove the word initially Notes for Abstraction Specifications Manual for Hospital Inpatient Quality Measures Page 24

No value should be selected more than once. If a value of A is selected, no other selection should be recorded. Example: Lovenox is ordered and substituted with dalteparin. Only abstract value 2 once, as both are LMWH. Abstract ALL VTE prophylaxis(s) that was administered the day of or the day after ICU admission or the day of or the day after Surgery End Date for surgeries that start the day of or the day after ICU admission. If no ICU VTE prophylaxis was administered during this timeframe, select value A. Selection of allowable values 1-8 includes any prophylaxis that was administered in the allowable time frame. Example: If a patient was admitted to ICU on 12/8/20xx and had bilateral GCS applied at 13:00 on 12/08/20xx and LMWH was administered at 22:00 on 12/9/20xx, select Values 2 and 4. If one pharmacological medication is ordered and another medication is substituted (such as per pharmacy formulary substitution or protocol), abstract the medication administered. Note: No copy of the formulary or protocol is required in the medical record. Example: Lovenox is ordered and not received and is substituted with fondaparinux sodium, which is received by the patient. Abstract fondaparinux sodium as Value 5 for ICU VTE Prophylaxis and abstract the date it was administered for ICU VTE Prophylaxis Date. If the patient received one of the pharmacologic anticoagulation medications for other reasons, select the allowable value that was administered during the specified timeframe. Example: If the patient received warfarin for atrial fibrillation on the day of ICU admission, select Value 6. Only select prophylaxis if there is documentation that it was administered. Documentation in the progress notes under assessment/plan: DVT prophylaxis SCD/Teds is not enough to select Values 3 and 4. Application of mechanical prophylaxis may be documented by any personnel. Example: Nursing assistant documentation of IPC application during the allowable timeframe is acceptable. ICU VTE Prophylaxis Date Rationale: The need for clarification of documentation that is acceptable for these data elements was identified through review of clinical scenarios by the Technical Advisory Panel. Definition Remove the word initial Specifications Manual for Hospital Inpatient Quality Measures Page 25

Suggested Data Collection Question Remove the word initial Notes for Abstraction Change first bullet to: The earliest date associated with a form of prophylaxis other than aspirin should be entered. Example: If the patient was admitted on 12/8/20xx and aspirin was administered at 13:00 on 12/8/20xx and LMWH was administered at 02:00 on 12/9/20xx, record the 12/9/20xx date. Suggested Data Sources Circulator s notes Graphic/flow sheets Medication administration record Nursing notes Operative notes Physician notes Preoperative nursing notes Progress notes Initial ECG Interpretation Rationale: Cases with an initial ECG finding of "Not a STEMI" should be excluded from the reperfusion measures. Notes for Abstraction Change sixth bullet to: If documentation regarding an Inclusion term is contradictory within the same interpretation or between different interpretations, select No. Examples: o ST-elevation and No ST-elevation o "Acute anterior MI" and "no acute MI" Note: Documentation such as "STEMI" and "No ST elevation" should not be considered contradictory, for the purposes of this data element. Exclusion Guidelines for Abstraction - ST-segment elevation Add new first bullet: Documentation of the absence of STEMI (in reference to the ECG performed closest to arrival) - e.g., No STEMI, not a STEMI, not consistent with STEMI, not diagnostic of STEMI Initial ECG Interpretation Specifications Manual for Hospital Inpatient Quality Measures Page 26

Rationale: The latest ACCF/AHA STEMI clinical guidelines no longer support taking LBBB on the presenting ECG as a criterion for candidacy for acute reperfusion. Definition ST-segment elevation based on the documentation of the electrocardiogram (ECG) performed closest to hospital arrival. The normal ECG is composed of a P wave (atrial depolarization), Q, R, and S waves (QRS complex, ventricular depolarization), and a T wave (ventricular repolarization). The ST-segment, the segment between the QRS complex and the T wave, may be elevated when myocardial injury (AMI) occurs. Suggested Data Collection Question Is there documentation of ST-segment elevation on the electrocardiogram (ECG) performed closest to hospital arrival? Allowable Values Change from: Y (Yes) ST-segment elevation or a LBBB on the interpretation of the 12-lead ECG performed closest to hospital arrival. To: N (No) Y (Yes) N (No) No ST-elevation or LBBB on the interpretation of the 12-lead ECG performed closest to hospital arrival, no interpretation or report available for the ECG performed closest to hospital arrival or unable to determine from medical record documentation. ST-segment elevation on the interpretation of the 12-lead ECG performed closest to hospital arrival. No ST-elevation on the interpretation of the 12-lead ECG performed closest to hospital arrival, no interpretation or report available for the ECG performed closest to hospital arrival or unable to determine from medical record documentation. Notes for Abstraction Change second bullet to: Do not measure ST-segments from the tracing itself. Remove seventh bullet: If at least one interpretation describes an LBBB as old, chronic, or previously seen, or states LBBB and "no changes," "unchanged," "no acute changes," "no new changes," or "no significant changes" when compared to a prior ECG, all LBBB findings should be disregarded. Inclusion Guidelines for Abstraction Remove: Left bundle branch block (LBBB) Specifications Manual for Hospital Inpatient Quality Measures Page 27

Intraventricular conduction delay of LBBB type Variable LBBB Exclusion Guidelines for Abstraction Remove: Left bundle branch block (LBBB) Incomplete left bundle branch block (LBBB) Left bundle branch block (LBBB), or any of the other left bundle branch block inclusion terms, described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table (except possible ) Left bundle branch block (LBBB), or any of the other left bundle branch block inclusion terms, with any mention of pacemaker/pacing (unless atrial only or nonfunctioning pacemaker) in one interpretation INR Value Rationale: The time frame for documentation reflecting the intended reason for not ordering overlap therapy needed to be defined. The time frame for determining INR value was defined and examples provided. Definition Documentation of an international normalized ratio (INR) value greater than or equal to 2.0 on the day of or the day after the last dose of the pareneteral anticoagulation therapy. This value correlates to the ability of the blood to clot. Suggested Data Collection Question Was there documentation of an INR value greater than or equal to 2.0 on the day of or the day after the last dose of the parenteral anticoagulation therapy? Allowable Values Change from: Y (Yes) There is documentation of an INR result greater than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy. N (No) To: Y (Yes) N (No) There is no documentation of an INR result greater than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy or unable to determine from medical record documentation. There is documentation of an INR result greater than or equal to 2.0 on the day of or the day after the last dose of the parenteral anticoagulation therapy. There is no documentation of an INR result greater than or equal to 2.0 the day of or the day after the last dose of the parenteral anticoagulation therapy or unable to determine from medical record documentation. Notes for Abstraction Specifications Manual for Hospital Inpatient Quality Measures Page 28

To determine the value for this data element, review the INR values the day of or the day after the last dose of the parenteral anticoagulation therapy was administered. If any result is greater than or equal to 2.0, select Yes. Examples: o On 1/1/20XX, after four days of overlap therapy, the INR is 1.8. On 1/2/20XX, the patient received enoxaparin, the INR is 2.0. Select Yes because the INR was equal to 2.0 on the day of or the day after the last dose of the parenteral anticoagulation therapy. o On 1/1/20XX, after four days of overlap therapy, the INR is 2.0. The last dose of dalteparin was on 1/2/20XX, on the same day, the INR was 1.8. The patient is discharged without parenteral anticoagulation therapy. Select No because the INR was not greater than or equal to 2.0 the day of or the day after the last dose of the parenteral anticoagulation therapy. o On 1/1/20XX, after five days of overlap therapy, the last dose of heparin is administered, the INR is 1.8. The patient is discharged without parenteral anticoagulation therapy. Select No because the INR was not greater than or equal to 2.0 on the day of or the day after the last dose of parenteral anticoagulation therapy. o On 1/1/20XX, after seven days of overlap therapy, the INR remains less than 2.0. On 1/2/20XX, the patient receives the last dose of enoxaparin and the INR equals 2.0. Select Yes because the INR is greater than or equal to 2.0 on the day of or the day after the last dose of parenteral anticoagulation therapy. IV Thrombolytic Initiation Rationale: This change is to remove Notes for Abstraction from the data element IV Thrombolytic Initiation which is counter-intuitive to the measure logic. Notes for Abstraction Remove fourth bullet: When IV thrombolytic therapy is initiated beyond 3 hours (180 min.) because a reason for not initiating IV thrombolytic therapy existed during the 3 hour timeframe, select No. Examples: o Patient arrives in the emergency department within 2 hours of time last known well. Blood pressure 195/110 mmhg on arrival. Physician documents that patient is within the t-pa window, but blood pressure is an issue. Elevated blood pressure treated prior to t-pa administration. IV thrombolytic therapy administered at 3 hours and 30 minutes from time last known well. o Patient arrives in the emergency department within 2 hours of time last known well and refuses t-pa. Family arrives and after further discussion with them, patient consents to t-pa. IV thrombolytic therapy administered 4 hours later. Suggested Data Sources Add new bullet: Specifications Manual for Hospital Inpatient Quality Measures Page 29

IV flow sheets Exclusion Guidelines for Abstraction Add new bullet: Thrombolytic administration to flush, open or maintain patency of a central line, e.g., PICC line. Last Known Well Rationale: This change is to clarify the abstraction guidelines for data elements that generate the majority of stroke abstraction questions and ease the burden of abstraction. Notes for Abstraction Select Yes if BOTH a Date Last Known Well and a Time Last Known Well are documented. Select No if there is ANY physician/apn/pa documentation that Last Known Well is UNKNOWN. Documentation must explicitly state that the Time Last Known Well is unknown/uncertain. If the time last known well is clearly greater than 2 hours prior to hospital arrival AND no specific time is documented, select No. Example: Patient OK last night. Select No because no other documentation of a specific time/time range/time reference was present in the medical record and the time is required for the Time Last Known Well. Documentation of Last Known Well or stroke symptoms that occurred at a date or time following hospital arrival (e.g., in-house stroke), select No. Suggested Data Sources Ambulance record Code Stroke form/template Emergency department records History and physical IV flow sheets Medication administration record Nursing flow sheets Progress notes Transfer sheet Remove: Excluded Data Sources: Discharge summary Measure Category Assignment Specifications Manual for Hospital Inpatient Quality Measures Page 30