Abstract T P301: Comprehensive Stroke Performance Measure Rates between Certified and Non-Certified Comprehensive Stroke Centers

Objective: To determine performance measure rates for the pilot-tested draft Comprehensive Stroke (CSTK) measures at Joint Commission (JC) certified CSCs compared to non-certified CSCs. Methods: Data from 66 pilot sites in 27 states that collected data on 7 potential CSC stroke measures were submitted to the JC. Of these 66 sites, 20 became JC certified CSCs, and 46 did not as of July2014. We compared performance measure rates between these 2 groups of facilities using Chi-square analysis. Results: Data from 9720 patients were analyzed. Aggregate measure rates ranged from 10.2% for CSTK-05 up to 71.6% for CSTK-01. Rates between CSC JC certified sites vs non-CSC sites showed the following results: CSTK-01, NIH Stroke Scale for ischemic stroke, 77.1% vs 69.2%, (p = 0.0001); CSTK-02, modified Rankin at 90 days, 37.2% vs 18.7%, (p = 0.0001); CSTK-03, ICH and SAH severity scales completed within 6 hours of hospital arrival or prior to surgery, 28.2% vs 14.8%, (p = 0.0001); CSTK-04, INR reversal agent administered for intracerebral hemorrhage and INR > 1.4 at hospital arrival , 52.9% vs 51.8%, (p = 0.87); CSTK-05, hemorrhagic complications after lytic or mechanical therapy for ischemic stroke, 10.6% vs 10.0%, (p = 0.88); CSTK-06, nimodipine treatment for aneurysmal SAH within 24 hours of arrival, 75.5% vs 68.1%, (p = 0.005); CSTK-07a, reperfusion rate recorded for endovascular therapy in ischemic stroke, 32.1% vs 33.4%, (p = 0.71). These pilot data do not reflect changes or improvements after the observation period. Conclusions: In this pilot study, JC certified CSCs performed somewhat better than other institutions on some CSC measures, especially in applying the utilization of various rating scales for stroke severity. Substantial room for improvements exist at most sites for most measures.