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Intracerebral hemorrhage (ICH) is a subtype of stroke that results from spontaneous nontraumatic bleeding into the parenchyma of the brain. ICH accounts for ≈10% to 15% of all strokes and carries a disproportionately high risk of early death and long-term disability.1 Evidence for optimal treatment of ICH has lagged be... |
However, numerous more recent studies and clinical trials of various medical and surgical interventions for ICH have been published and form the basis of evidence-based guidelines for the management of ICH that have been devel- oped by the American Heart Association (AHA)/American Stroke Association (ASA) and other int... |
A clinical performance measure is defined by the Agency for Healthcare Research and Quality as “a mechanism for assessing the degree to which a provider competently and safely delivers the appropriate clinical services to the patient within the optimal time period.”5 Performance measures are being increasingly used for... |
Rigorous performance measures often take the strongest high- est-level guidelines and provide a method for directly measur- ing and reporting them with the goal of improving healthcare In addition to being evidence-based, they need to be developed with attention to feasibility and whether they are actionable and clearl... |
TheAmerican HeartAssociation makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and sub... |
A copy of the document is available at http://professional.heart. org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com. A Data Supplement is available with this article at https://ww... |
Clinical performance measures for adults hospitalized with intracerebral hemorrhage: performance measures for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49:e243–e261. doi: 10.1161/ STR.0000000000000171. The expert peer review of AHA-commissioned documents (eg,... |
Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright- Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page. AHA/ASA Performance Measures development that has been used for other AHA cardiova... |
The present document on ICH follows that ischemic stroke document substantially, borrowing wording when appro- priate to ensure similarity and harmonization across AHA/ ASA performance measure approaches.10 The process was overseen by the AHA/ASA Stroke Performance Oversight Committee and coordinated by an independent ... |
Methods The process used by the AHA/ASA ICH Performance Measure Writing Group was adapted from the methodology developed jointly by the American College of Cardiology and AHA for the development of performance measures for cardiovascular The writing group was tasked by the AHA to develop performance measures related to... |
Group members then reviewed existing AHA/ASA guidelines relevant to ICH for suitability for con- version to performance measures on the basis of the strength of guideline recommendation and evidence base, feasibility of data collection, reliability for comparison across hospitals, and potential to improve patient outco... |
Previously existing performance measures that might apply to ICH that were already developed or endorsed by the National Quality Forum (NQF) or other groups such as the Centers for Disease Control and Prevention (CDC) or The Joint Commission (TJC) were also reviewed, and when possible, an attempt was made to harmonize ... |
New measures deserve pilot testing before widespread adoption. Structure and Membership of the Writing Group The writing group was selected by the AHA/ASA Stroke Performance Oversight Committee and was designed to include a diverse set of experienced clinicians with expertise in both the guideline-concordant management... |
Work was conducted via multiple confidential conference calls and e-mail; in-person writing group meetings did not occur. Disclosure of Relationships With Industry All members of the writing group were volunteers who donated their time and efforts without monetary or other com- pensation. Writing group members were req... |
There are multiple different causes for ICH, including hypertension, coagulopa- thy, underlying vascular anomalies, sympathomimetic drugs of abuse, and cerebral amyloid angiopathy. These perfor- mance measures are meant to apply to the same condition described in the AHA/ASA “Guidelines for the Management of Spontaneou... |
These performance measures also do not apply to acute ischemic stroke or subarachnoid hemor- rhage, which are the subject of other current or future docu- ments. In addition, these performance measures are intended for patients for whom the principal reason for hospital admis- sion is ICH. Patients who are admitted to ... |
Although these patients should generally be treated according to the ICH guidelines, concerns of the writing group about the feasibility of case ascertainment, diagnosis attribution, and data reliabil- ity led to exclusion of these patients from documented assess- ment with these performance measures. Table 1 includes ... |
ICD-10-CM Principal Diagnosis Codes for Eligible Patients With an ICH Diagnosis I61.0 Nontraumatic ICH in hemisphere, subcortical I61.1 Nontraumatic ICH in hemisphere, cortical I61.2 Nontraumatic ICH in hemisphere, unspecified I61.3 Nontraumatic ICH in brainstem I61.4 Nontraumatic ICH in cerebellum I61.5 Nontraumatic I... |
Adapted from the Centers for Medicare and Medicaid Services ICD-10 Assessment and Maintenance Toolkit.13 Hemphill et al Performance Measures for ICH e245 Clinical Modification principal diagnosis codes for eligible patients with an ICH diagnosis in whom these performance measures are considered applicable. Dimensions o... |
As with acute ischemic stroke, it is recognized that there are multiple dimensions of care for ICH, including the prehospital setting, the emergency depart- ment, rehabilitation, and outpatient care directed at primary and secondary prevention. |
Most other stroke-related performance measures (such as those from TJC,13 AHA’s Get With The the the CDC’s Paul Coverdell National Acute Stroke Program,15 and the AHA/ASA ischemic stroke ) have used the inpatient setting for this purpose because it represents a well-identified period of care that generally has good doc... |
The writing group discussed the feasibility of assessment of performance measures in various settings and felt that restricting the dimension of care to the acute inpatient setting was a reasonable compromise for this first set of ICH performance measures. It was felt important that all hospitals involved in the acute ... |
In addition, it would be most desirable for performance measures to be directly linked to patient-specific outcomes as opposed to processes of care.17 Outcomes can be intermediate- term or acute outcomes (eg, development of pneumonia during the inpatient setting) or long-term outcomes (eg, functional out- come at 6 mon... |
Ultimately, consideration of feasibility of measurement and harmonization with existing performance measures from other organizations (especially those measures that are NQF endorsed) weighed substantially in the decisions on which performance measures to put forth and how they should be structured. |
Literature Review The primary source for review of potential performance mea- of Spontaneous Intracerebral Hemorrhage.”2 AHA/ASA “Guidelines for Adult Stroke Rehabilitation and Recovery” were also reviewed.18 In addition, other documents of existing performance measures or quality metrics were reviewed to assess whethe... |
The AHA/ASA “Metrics for Measuring Quality of Care in Comprehensive Stroke Centers” and “Clinical Performance Measures for Adults Hospitalized With Acute Ischemic Stroke” were reviewed for potential measures that would apply to ICH and should be considered for inclusion.10,19 Currently active per- formance measures fro... |
Selection and Development of Performance Measures The process for the selection and development of these ICH performance measures used an approach from the AHA/ASA Stroke Performance Oversight Committee similar to that used for the 2014 AHA/ASA ischemic stroke performance mea- Only Class I (high consensus for benefit) ... |
Potentially applicable metrics from the AHA/ASA “Metrics for Measuring Quality of Care in Comprehensive Stroke Centers” manuscript were also added to the list for consideration.19 Standard criteria for performance measure development were determined before initial review and were derived from principles set forth previ... |
On the basis of the writing group discussion and voting, if a specific guideline recommendation was felt not to meet the above criteria, then it was not moved forward for development as a potential performance measure. From this list of potential performance measures, sub- groups of the writing group developed formal m... |
Each writing group member participated in the development of at least 2 draft performance measures. Subsequent teleconferences were held in which each of these drafts was reviewed by the writ- ing group with input designed to improve the measurement set specifications before voting by the writing group. During these te... |
Each measure was then voted on for inclusion or exclu- sion with a standardized ballot form that included a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) on various aspects concerning suitability for submission as a performance measure. The ballots allowed measures to be rated separately on thes... |
Review and Endorsement In February 2017, the ICH performance measures document underwent a 30-day public comment period, during which AHA members and other healthcare professionals had an opportunity to review and comment on the measurement set specifications for each of the 9 specific performance measures proposed. Re... |
When deemed appropriate, these changes were made before the development of this final manuscript describing the ICH performance measures. Peer review of this manuscript was then conducted by reviewers selected by the AHA. After peer review and appropriate revi- sions, these ICH performance measures were approved by the... |
Performance Measures for Adults Hospitalized With ICH Patient Population and Care Period The patient population is patients with spontaneous ICH, as defined in Definition of ICH in the Methods section, and the care period is the acute hospitalization for diagnosis and management of new ICH, from emergency department ar... |
For patients who are initially seen at 1 hospital (in the emer- gency department or hospital intensive care unit or ward) and transferred to another hospital, care at both hospitals is eli- gible for assessment with these performance measures based on the measures that would be relevant for the extent of care delivered... |
Accordingly, these admission types are excluded from the measure denominators, as they are for current NQF-endorsed ICH measures. The writing group agreed that it is appropriate to exclude admissions with length of stay >120 days, as is done in the NQF-endorsed ICH measures, to avoid double counting patients when gener... |
International Classification of Diseases, 10th Revision, Clinical Modification codes for ICH are shown in Table 1. The choice of method of case ascer- tainment and diagnosis via administrative billing codes versus chart review may depend on many registry-specific factors, including available resources, and the writing ... |
This includes several measures that are already endorsed as ICH performance measures by other organizations, some that are analogous to measures already endorsed by others but revised either to make them directly relevant to ICH (venous thromboembolism prophylaxis) or to harmonize with isch- emic stroke measures (2 dys... |
For example, 2 measures are currently already endorsed by the NQF, and 3 have analogous measures that are similar to NQF-endorsed measures but were revised for this ICH measure set.20 Two are currently part of TJC Primary and Comprehensive Stroke Center criteria, and 1 measure is similar to a Comprehensive Stroke Cente... |
The Discussion provides additional comments on the measures, including the limitations of some of the current measures, opportunities for improvement, and rec- ommendations for implementation and field testing. Appendix Table A1 provides full specifications for each measure. Data Collection The process whereby data are... |
The move of hospitals and healthcare systems to electronic health records means that some data ele- ments can be automatically captured through these systems. Some data elements (eg, laboratory results or medications dis- pensed) have highly structured elements in electronic health records that facilitate automatic dat... |
Capturing and verifying the accuracy of these elements and other crucial clinical data Hemphill et al Performance Measures for ICH e247 (eg, a contraindication to a process) may still require manual chart review and abstraction. Regardless of how the data are collected, the reliability of data abstraction methods used ... |
To avoid bias and to ensure accurate numerators and denominators for reporting of overall hospital compliance with these performance measures, we recommend that data should be collected on all consecutive patients rather than a convenience sample. Discussion The goal of this project has been to develop an ICH-specific ... |
Each performance mea- sure derives directly from a Level I or Level III recommenda- tion from the 2015 AHA/ASA ICH guidelines, although in several instances the specific wording and construction of the performance measures were revised or enhanced to harmonize with existing performance measures in use from other orga- ... |
The purpose of these performance measures is to improve the quality of care for patients with ICH by providing hospitals, stroke teams, and regulatory bodies with a way to directly measure and potentially benchmark this quality of care. The writing group, through its internal discussions and deliberations, understands ... |
However, concordance with current guideline-recommended care is strongly encouraged even in the absence of a specific perfor- mance measure linked to all aspects of care. It is hoped that this proposed ICH performance measure set will provide an initial toolkit for assessing quality of care and that it will be revised ... |
They may be useful in other countries as well, either as directly assessed performance mea- sures or as an example by which other countries may assess appropriate ICH performance measures optimized for their own system of care. |
When adoption outside the United States is considered, it is appropriate to consider the relevance of the specific aspects of each performance measure to local context and modify if needed.21 In addition, these performance mea- sures are intended to complement similar existing efforts by other organizations and regulat... |
This is why significant effort was made to harmonize these performance measures with other existing measures, espe- cially when these earlier measures had been endorsed by the NQF. When the writing group felt that an existing performance measure was not optimal, the relevant performance measure was made according to wr... |
The writing group spent a substantial amount of time discussing whether patient outcomes could be used rather than process, and this was the initial desire for several of the original drafts of performance measure specification sets. Examples of this could include less hematoma expansion with timely coagulopathy revers... |
Performance Measure NQF Endorsed CDC PCNASR/AHA GWTG-Stroke TJC CMS HIQRP AHA Ischemic Stroke Performance Measure New Measure 1 Baseline severity score 2 Coagulopathy reversal o 3 Venous thromboembolism prophylaxis o o o o o 4 Admission unit 5 Dysphagia screen: assessment o o 6 Dysphagia screen: management o o ... |
gap remains between many processes of care derived from evi- dence-based guidelines and performance metrics that meet the various criteria such as feasibility, interpretability, and ability to be reliably and directly measured in the context of current stroke care. Consequently, most if not all current and endorsed ICH... |
The writing group felt that as the field of quality assessment and performance measurement moves forward in stroke, priority should be placed on piloting outcome assess- ment for various performance measures with the goal of future transition from process measurement to patient-based outcome measurement. What follows i... |
The recommendation for a baseline severity score in all patients with acute ICH was new in the 2015 AHA/ASA ICH guidelines and was considered as a metric for Comprehensive Stroke Centers in the 2011 AHA/ASA recommendations. Numerous baseline severity scores for ICH exist,22–24 with the general goal of their use being t... |
Whether to require a specific baseline severity score (such as the ICH score22 ) or to allow any of a variety of existing severity scores (such as the FUNC [Functional Outcome in Patients with Primary Intracerebral the Glasgow Coma Scale score, the National Institutes of Health Stroke Scale score, or others as chosen b... |
TJC requires a baseline ICH severity score as part of its metrics for Comprehensive Stroke Centers, and the ICH score is the only severity score used in this context. This TJC performance measure is endorsed by the NQF. Thus, the writing group felt that harmonization with the existing NQF-endorsed measure was a high pr... |
Components of the ICH score and 1 straight- forward method of calculating ICH hematoma volume can be found in work by Hemphill et al22 and Kothari et al.25 The performance measure for reversal of coagulopathy follows from the 2015 AHA/ASA ICH guidelines Class I rec- ommendation for discontinuation of vitamin K antagoni... |
The 2015 ICH guidelines do not provide a Class I recommendation as to whether to use prothrombin complex concentrates or fresh-frozen plasma and do not specify a time frame in which therapy must be administered. |
The optimal therapy and timing for vitamin K antagonist reversal in acute ICH have received notable atten- tion in the time since the literature review for the 2015 ICH Although a recent clinical trial sug- gested superiority of prothrombin complex concentrates over the writing group felt that the level of existing rec... |
However, the writing group felt that the absence of any time frame for administra- tion did not appropriately reflect quality because treatment with prothrombin complex concentrates or fresh-frozen plasma at a time point outside the hyperacute period was not the intended approach and meeting the metric by treat- ing ma... |
Thus, initiation within 90 minutes of emergency department presentation (door-to-needle time) was chosen for this perfor- mance measure because it combines the expected time frame for the initial head computed tomography in stroke evaluation with treatment timing from a recent clinical trial of coagu- lopathy reversal.... |
Per the recommendation in the 2015 ICH guidelines, intravenous vitamin K must also be administered to meet this performance measure. The fact that this measure applies to the present- ing hospital (or a transfer-receiving hospital if therapy was not started at the initial hospital) was considered important because it e... |
This measure deserves pilot test- ing, and it is reasonable for additional data such as type of treatment (prothrombin complex concentrates or fresh-frozen plasma) and time to international normalized ratio correction to be recorded. Again, public comment was generally support- ive of the requirement of an early time f... |
However, this is an important issue for future guideline and performance measure updates. Venous thromboembolism prophylaxis exists as a mea- sure for patients with ICH in the CDC’s Paul Coverdell National Acute Stroke Program and is an NQF-endorsed measure. An analogous performance measure is present in the AHA/ASA is... |
However, the use of pneumatic compres- sion devices on the day of hospital admission is a Class I rec- ommendation from the 2015 AHA/ASA ICH guidelines and is required to successfully meet this performance measure. For purposes of harmonization with analogous performance measures from other groups, use of pneumatic com... |
All 3 of these measures derive from an independent Class I rec- ommendation in the 2015AHA/ASA ICH guidelines. However, these are also issues that generally apply to all stroke patients, Hemphill et al Performance Measures for ICH e249 and this factored significantly into the writing group’s delib- erations on whether ... |
In the 2014 AHA/ASA ischemic stroke performance measures, there is extensive discussion of the challenges and controversies concerning the use of dyspha- gia screening as a performance measure.10 In that document, the decision was made to create 2 dysphagia measures, 1 mea- sure for screening within 24 hours of hospita... |
The ICH perfor- mance measure writing group extensively discussed the exist- ing controversies in dysphagia screening and ultimately felt that harmonization with the 2 measures from the ischemic stroke set made the most sense. |
Similarly, the writing group recognized that the performance measure requiring assessment for rehabili- tation is associated with high compliance already and does not specify the type of rehabilitation services provided.29 Even so, the writing group felt it was important to have a performance measure that pertained to ... |
These new measures deserve pilot testing to assess feasibility and reliability. The new measures relate to hospital admission unit, long-term blood pressure management, and corticosteroid use for intracranial pressure management. It is recognized that for ICH specifi- cally, improved outcomes are seen in patients who a... |
It appears that this effect is in addition to the impact of any 1 specific targeted intervention and may indi- cate that hospital units such as these create a milieu in which overall care is optimized.30–32 Although there is not an exist- ing analogous performance measure from other organizations, TJC requires that cer... |
This emphasizes the importance of stroke systems of care. A poten- tial challenge related to the implementation of this measure is verification of expertise in such hospital units. The 2015 AHA/ ASA ICH guidelines do not provide specifics for how this can be assessed; TJC indicates that specialized training, includ- in... |
Hypertension is the most common cause of ICH, and the 2015 AHA/ASA ICH guidelines contain a new prevention- focused recommendation for the initiation of blood pressure control immediately after ICH onset.1,2 The related new perfor- mance measure does not apply to specific targets or agents for acute blood pressure cont... |
The writ- ing group ideally preferred a measure that directly assessed achieving long-term blood pressure control as an outpatient after ICH. However, development of this into a performance measure was not considered feasible or actionable at this time because of the often limited information on outpatient records and ... |
As a new perfor- mance measure, pilot testing is warranted, and it is hoped that, with the advance of electronic medical records, a future per- formance measure might target documentation of long-term compliance and control. The new AHA definition of hyperten- sion as a blood pressure >130/80 mmHg was incorporated as t... |
Some members of the writing group felt this was a rare occurrence and thus a performance measure focusing on this was likely to have very high compliance already. However, other members were concerned that there was still substan- tial use. Pilot testing during initial implementation may help clarify this. Note that th... |
Conclusions Nine performance measures are proposed as part of this initial AHA/ASA clinical performance measure set for adults hospi- talized with ICH. Six either are existing performance measures that are NQF endorsed (n=2) or have analogous performance measures through other organizations or related disease pro- cess... |
Many more issues were considered for performance measures but did not meet the criteria for inclusion in this set (Supplemental Table 1). In addition, the writing group recognizes that there are many issues that might be desirable in performance mea- sures but do not currently meet the high evidence standards (Class I ... |
Quality assessment and performance measure implementation in stroke are still at an early stage, and it is hoped that future advancement of the evidence base for ICH care and broader experience with testing and implementation of performance measures will lead to revisions and expansions with the ulti- mate goal of impr... |
Baseline Severity Score: Percentage of patients with ICH in whom a baseline severity score is measured and a total score is recorded as part of initial evaluation on arrival at the hospital Numerator Patients in whom an initial severity score is measured and a total score recorded within 6 h of hospital arrival. If an ... |
Denominator Included patients: All patients with ICH Excluded patients: <18 y of age Patients who arrive at hospital >48 h after last known well time Length of stay >120 d Clear documentation for comfort care/palliative care measures established before hospital arrival Period of Assessment First 6 h after hospital arri... |
Measurement of a validated standardized severity score is important for prioritizing interventions, such as intensive care unit admission and surgical intervention, is the main determinant of short-term and long-term prognosis, facilitates communication of stroke severity between survivors, and is essential for risk ad... |
A baseline severity score should be performed as part of the initial evaluation of patients with ICH (Class I; Level of Evidence B). Method of Reporting Per patient: documentation of whether a severity score was measured and a total score was recorded as part of the initial evaluation on arrival at the hospital Per pat... |
Measuring an intracerebral-specific score, such as the ICH score, within 6 h of arrival may be challenging for hospitals without an on-site stroke team, as opposed to a more general measure such as the GCS (which is a component of the ICH score). When hematoma volume is measured as part of a baseline severity score, a ... |
2866) AHA indicates American Heart Association; ASA, American Stroke Association; CSTK, Comprehensive Stroke; GCS, Glasgow Coma Score; ICH, intracerebral hemorrhage; NQF, National Quality Forum; and TJC, The Joint Commission. Hemphill et al Performance Measures for ICH e251 Appendix. Continued 2. |
Coagulopathy Reversal: Percentage of patients with ICH and an INR >1.4 resulting from warfarin treatment who receive therapy to replace vitamin K–dependent clotting factors within 90 min of ED presentation and who also receive intravenous vitamin K* Numerator Patients with an INR >1.4 resulting from warfarin treatment ... |
Time to correction of an elevated INR caused by warfarin has been related to amount of hematoma expansion. Prothrombin complex concentrates and fresh-frozen plasma decrease the INR and quickly reverse the anticoagulant effect of warfarin. Vitamin K is needed to ensure that coagulopathy does not return after the effect ... |
Source for Recommendations From the 2015 AHA/ASA “Guidelines for the Management of Spontaneous Intracerebral Hemorrhage” Patients with ICH whose INR is elevated because of vitamin K antagonist should have their vitamin K antagonist withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, an... |
Method of Reporting Per patient: documentation of administration of therapy to replace vitamin K–dependent clotting factors within 90 min of arrival to the presenting ED Per patient population: percentage of patients treated with therapy to replace vitamin K–dependent clotting factors within 90 min of arrival to the pr... |
Analogous Measures Endorsed by Other Organizations Analogous measure used by TJC (CSTK-04) AHA indicates American Heart Association; ASA, American Stroke Association; CSTK, Comprehensive Stroke; ED, emergency department; ICH, intracerebral hemorrhage; INR, international normalized ratio; and TJC, The Joint Commission. ... |
Recombinant factor VIIa is not recommended by the AHA/ASA ICH guidelines and is not acceptable. Appendix. Continued 3. |
Venous Thromboembolism Prophylaxis: Percentage of patients with ICH who receive lower limb pneumatic compression on hospital day 0 or 1 Numerator Patients who received VTE prophylaxis using lower limb pneumatic compression on the day of admission (day 0) or the day after admission (day 1) or who have documentation why ... |
DVT is common in patients with ICH because of decreased mobility. The CLOTS trials demonstrated that pneumatic compression is superior to the use of graduated compression stockings and that DVT occurrence is reduced, especially in patients with ICH, if pneumatic compression was started as early as the day of hospital a... |
Graduated compression stockings are not beneficial to reduce DVT or improve outcome (Class III; Level of Evidence A). Method of Reporting Per patient: documentation of whether patient received pneumatic compression on hospital day 0 or 1 Per patient population: percentage of patients receiving pneumatic compression on ... |
0434), TJC (STK-1), AHA Ischemic Stroke Performance Measure 1, AHA GWTG–Stroke, CDC PCNASP, and CMS HIQRP AHA indicates American Heart Association; ASA, American Stroke Association; CDC, Centers for Disease Control and Prevention; CLOTS, Clots in Legs or Stockings After Stroke; CMS, Centers for Medicare & Medicaid Serv... |
*Acceptable contraindications to the use of pneumatic compression include any local leg condition in which the sleeves may interfere, such as dermatitis, vein ligation (immediately postoperative), gangrene, recent skin graft, severe peripheral arterial disease, existing DVT, or severe congestive heart failure with pulm... |
Admission Unit: Percentage of patients with ICH who are admitted to an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise Numerator Patients admitted to an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise Den... |
Care of patients with ICH in a dedicated neuroscience intensive care unit is associated with a lower mortality rate. Stroke units have demonstrated improved long-term outcome in randomized trials. Presence of a stroke unit is a required component for Primary and Comprehensive Stroke Center certification by TJC. Source ... |
Method of Reporting Per patient: documentation of whether a patient was admitted to an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise Per patient population: percentage of patients with ICH admitted to an intensive care unit or dedicated stroke unit with physic... |
Analogous Measures Endorsed by Other Organizations For certification, TJC requires Primary Stroke Centers to have a “stroke unit or designated beds for the acute care of stroke patients” and Comprehensive Stroke Centers to have “dedicated neuro-ICU [intensive care unit] beds for complex stroke patients that include sta... |
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