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:
- Deep Vein Thrombosis (DVT) or pulmonary embolism (PE)
- Aspiration pneumonia
- Fall as defined as an unplanned descent to the floor with or without injury
- Urinary Tract Infection (UTI)
- 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.