Minnesota Stroke Registry Program
Program Manual
August 2012
Welcome to the Minnesota Stroke Registry Program!
Stroke is the third leading cause of death in the United States and Minnesota and is a leading cause of
severe, long term disability. Effective acute stroke care is dependent on the rapid identification of stroke
symptoms, the immediate activation of the EMS system, and delivering the stroke victim to an
institution capable of providing appropriate assessment and treatment. Effective treatment and
management can lead to a higher quality of life, reduce deaths and disability.
In 2000, in response to the growing concern regarding acute stroke care, the Centers for Disease Control
and Prevention (CDC) established the CDC Paul Coverdell National Acute Stroke Registry Program. The
program was named after Senator Paul Coverdell from Georgia who died of a stroke. This program
tracks the care delivered to hospitalized stroke patients in order to monitor and improve the quality of
stroke care. The Minnesota Department of Health received funding in 2007 from CDC to launch the
Minnesota Stroke Registry Program. Our statewide quality improvement program is designed to support
efforts to improve and maintain the quality care for acute stroke patients. We hope that your hospital
will join our effort to ensure that all Minnesotans receive the best stroke care possible!
This program manual describes the program tracks, requirements for participating hospitals, program
offerings, and data abstraction guidance.
Minnesota Stroke Registry Program Manual
Page 2
Original Release: 8/14/12
Updated: 8/14/12
Table of Contents
Program Tracks ............................................................................................................................................. 5
Track 1: Minnesota Stroke Registry–Coverdell (MSR-Coverdell).............................................................. 5
Track 2: Minnesota Stroke Registry–Emergency Stroke Care (MSR-ESC) ................................................. 5
Program Requirements ................................................................................................................................. 5
Reporting .................................................................................................................................................. 5
Quality Improvement ................................................................................................................................ 6
Program Offerings ......................................................................................................................................... 6
Hospital Stroke Program Visit/Assessment .............................................................................................. 6
Performance Improvement Collaboratives (optional) .............................................................................. 6
Regional Workshops (optional)................................................................................................................. 6
Analysis support ........................................................................................................................................ 7
Technical Assistance ................................................................................................................................. 7
Summary of Program Benefits ...................................................................................................................... 8
Enrollment Process ....................................................................................................................................... 9
Performance Measures, Quality Indicators, and Reports........................................................................... 10
CDC Paul Coverdell National Acute Stroke Registry Performance Measures ..................................... 10
Minnesota Stroke Registry – Emergency Stroke Care Indicators ....................................................... 10
Data Abstraction Toolkit ............................................................................................................................. 11
Data Abstraction…At-A-Glance ............................................................................................................... 11
Case Definition ........................................................................................................................................ 11
Case Ascertainment ................................................................................................................................ 14
Abstraction Deadlines ............................................................................................................................. 15
Data Elements ......................................................................................................................................... 15
Dictionary ................................................................................................................................................ 15
Data Submission Options ........................................................................................................................ 16
MSR-Coverdell..................................................................................................................................... 16
MSR-Emergency Stroke Care (ESC) ..................................................................................................... 16
Minnesota Stroke Registry Tool (MSRT) ................................................................................................. 17
Obtain a User Account ........................................................................................................................ 17
Administration and Access.................................................................................................................. 17
Logging in ............................................................................................................................................ 17
Minnesota Stroke Registry Program Manual
Page 3
Original Release: 8/14/12
Updated: 8/14/12
Setting up User Accounts .................................................................................................................... 18
Navigation ........................................................................................................................................... 19
Creating a new case ............................................................................................................................ 19
Closing a Case...................................................................................................................................... 20
Removing a Case ................................................................................................................................. 21
Special Feature: Patient Care Staff Tab............................................................................................... 22
Resources ............................................................................................................................................ 23
Reports ................................................................................................................................................ 24
Data Exchange..................................................................................................................................... 25
Case Report Forms .............................................................................................................................. 25
Patient Management Tool™ ................................................................................................................... 26
Background: Get With The Guidelines
Program .............................................................................. 26
Registration and Training .................................................................................................................... 26
Data submission .................................................................................................................................. 26
Removing a Case ................................................................................................................................. 26
Reports ................................................................................................................................................ 26
Resources and Information ................................................................................................................. 26
Case Count Confirmation ........................................................................................................................ 27
Chart auditing ......................................................................................................................................... 29
Appendix A: Data Elements ........................................................................................................................ 33
Table 1. MSR-Coverdell: Required Data Elements .................................................................................. 33
Table 2. MSR-Emergency Stroke Care: Required Data Elements ........................................................... 36
Table 3. Optional Data Elements ............................................................................................................ 37
Appendix B: Minnesota Stroke Registry Quality Indicators (Optional)....................................................... 39
Appendix C: Participant Checklist ............................................................................................................... 40
Contact Information.................................................................................................................................... 41
Minnesota Stroke Registry Program Manual
Page 4
Original Release: 8/14/12
Updated: 8/14/12
Program Tracks
Track 1: Minnesota Stroke Registry–Coverdell (MSR-Coverdell)
Track 1, MSR-Coverdell is designed for hospitals that admit the majority of their stroke patients. All
hospitals – metropolitan and rural – are welcome to join this track. The focus of this first track is on both
emergency department and inpatient care processes. Data collected by hospitals in this track will meet
stroke core measure reporting requirements and statewide quality reporting and measurement system
requirements.
Track 2: Minnesota Stroke Registry–Emergency Stroke Care (MSR-ESC)
Track 2, MSR-Emergency Stroke Care (MSR-ESC) is designed for hospitals that transfer the majority of
their patients out of the emergency department. The focus of this second track is on emergency
department care processes. Data collected by hospitals in this track will meet statewide quality
reporting and measurement system requirements.
Program Requirements
Program participants are expected to meet the following requirements.
Reporting
Track 1: MSR-Coverdell
- MSR-Coverdell hospitals are required to submit data found in Appendix A, Table 1.
o The Minnesota Department of Health will submit data to CDC from only hospitals
participating in the MSR-Coverdell track.
o Data may be submitted using the Minnesota Stroke Registry Tool (Standard module) or
the Patient Management Tool™ (through the American Heart Association’s Get With
The Guidelines-Stroke Program™).
- Abstraction Schedule: All eligible case records should be completed up through three months
prior to the current date. The Minnesota Department of Health will monitor abstraction
completion rates twice per year (June and December).
- Chart audits are conducted annually on a small sample of cases from MSR-Coverdell hospitals.
Track 2: MSR-Emergency Stroke Care (MSR-ESC)
- MSR-ESC hospitals are required to collect and submit data according to Appendix A, Table 2.
o Note: MDH will only submit summary (aggregate) data from MSR-ESC hospitals to CDC.
No case level data will be submitted to CDC.
- Schedule: All eligible case records should be completed up through three months prior to the
current date. The Minnesota Department of Health will monitor abstraction completion rates
twice per year (June and December).
-
Note: Chart audits are not conducted for hospitals participating in the MSR-ESC track.
Minnesota Stroke Registry Program Manual
Page 5
Original Release: 8/14/12
Updated: 8/14/12
Quality Improvement
All Minnesota Stroke Registry Program participants are expected to be actively engaged in quality
improvement projects and/or activities throughout the year. This includes the following activities:
-
-
-
All hospitals must identify a stroke program coordinator.
The stroke program coordinator should review the hospital’s performance measure and quality
indicator data quarterly at a minimum.
All hospitals must convene a multidisciplinary hospital stroke committee at least quarterly. This
committee should review the hospital’s quality improvement data and oversee the
implementation of performance improvement projects.
All hospitals must implement at least one performance improvement project or activity that
impacts the quality of stroke patient care, using an evidence-based quality improvement
approach or methodology (e.g., LEAN, Six Sigma, PDSA).
All hospitals must provide MDH with a brief report on their quality improvement projects at
least once per year. The format of this brief report will be determined by MDH.
Program Offerings
The Minnesota Department of Health offers several services and programs for program participants.
Generally, these are optional offerings.
Hospital Stroke Program Visit/Assessment
All MSR-Coverdell hospitals will be required to host an annual stroke program visits. The primary
purpose of the visit is to assist hospitals in identifying areas in which their stroke program may need
improvement. These visits will be our opportunity to keep track of what hospitals are doing for
performance improvement and inventory their current stroke care capacities. In addition, these visits
will help hospitals identify areas that will need to be addressed in preparation for designation
requirements for participation in the Minnesota Acute Stroke System (forthcoming). These visits will be
optional for MSR-ESC hospitals. Visits may be conducted in person or by teleconference, subject to
scheduling and travel constraints.
Performance Improvement Collaboratives (optional)
Performance Improvement Collaboratives are modeled after the Institute of Healthcare Improvement
(IHI) Breakthrough Series. Hospitals commit to working on improvement on a single performance
measure. A series of learning sessions are scheduled over a one year period. These learning sessions
include a lecture, time for sharing experiences, and reports on progress. In between learning sessions,
hospitals conduct their “homework” – purposeful efforts to implement a plan-do-study-act cycle of a
quality improvement initiative. The Minnesota Department of Health facilitates one collaborative every
year, spanning a 15 month period. (Contact: [email protected])
Regional Workshops (optional)
The Minnesota Stroke Registry Program is pleased to host regional workshops on clinical stroke care
topics and issues. Our goal is to bring education opportunities to hospital-based providers on current
Minnesota Stroke Registry Program Manual
Page 6
Original Release: 8/14/12
Updated: 8/14/12
stroke issues. These workshops will offer continuing education and contact hours for physicians, nurses,
and other allied health professionals. All hospitals in Minnesota, regardless of their participation in the
Minnesota Stroke Registry Program, are welcome to attend regional workshops.
(Contact: [email protected])
Analysis support
The Minnesota Department of Health provides data analysis support for all Minnesota Stroke Registry
Program hospitals. Hospitals may run their own data reports using the Minnesota Stroke Registry Tool
(MSRT) or the Patient Management Tool™ (PMT, for hospitals participating in the Get With The
Guidelines-Stroke Program). However, additional analysis (customized reports) may be requested by
the hospital. (Contact: Jim Peacock, [email protected])
Technical Assistance
The Minnesota Department of Health provides data abstraction and quality improvement technical
assistance. New hospitals are provided training on data abstraction through a short web-based
teleconference or in-person visit. In addition, we are committed to trying to answer abstraction
questions within 24 hours. If we are unable to provide an answer immediately, we will respond promptly
to inform you that we have received the question and are pursuing an answer. Finally, we host an
annual abstraction workshop in St. Paul to provide guidance on abstraction issues.
(Contact: [email protected])
Assistance regarding quality improvement for stroke patients is also available. We are committed to
providing hospitals with resources and information about performance improvement. (Contact:
[email protected])
Summary of Program Activities, by MSR Program Track
Activity
MSR-Coverdell
Data Abstraction
Full data
abstraction
Deadline for abstraction
3 months
Chart audits (annual)
Yes
Performance Improvement Project (at least
Yes
one per year)
Establishment of a hospital stroke committee
Required
Annual stroke program visit
Required
Abstraction Workshop
Optional
Performance Improvement Collaborative
Optional
Regional Workshops
Optional
Data analysis support
Optional
Technical Assistance
Optional
Minnesota Stroke Registry Program Manual
Page 7
MSR-ESC
Emergency Stroke Care
Indicators
3 months
No
Yes
Required
Optional
Optional
Optional
Optional
Optional
Optional
Original Release: 8/14/12
Updated: 8/14/12
Summary of Program Benefits
Data collection tool options. Our secure online data entry tool, is available to all participating hospitals at no
cost. Alternatively Hospitals may also participate in the American Heart Association’s Get With The GuidelinesStroke program and use the Patient Management Tool™.
Real-time Reporting. Hospitals can track their performance using our real-time reports.
Real-time benchmarking. Compare your hospital performance in real-time performance to other
hospitals in Minnesota and nationwide.
Patient-Level Reporting. Output lists of patients for whom a performance measure was missed.
Physician/Staff Tracking. Track staff performance in order to support peer-to-peer discussions.
Meet State and Federal Reporting Requirements. Participants meet reporting requirements for the
Minnesota Department of Health, Joint Commission Primary Stroke Center Disease-Specific Care program, and the
Centers for Medicare and Medicaid Inpatient Quality Reporting program.
Auditing Support. Our free audits meet Joint Commission Primary Stroke Center data monitoring requirements.
Data analysis support. The MSR program team provides analysis for participating hospitals on request.
Quality Improvement Support. Participate in a performance improvement collaborative; request technical
assistance from the Minnesota Department of Health.
Educational Opportunities. Regional educational workshops are open to all hospitals in Minnesota.
Visibility. Participation will increase the visibility of your program and highlight your high quality stroke care.
Opportunity to help improve patient care. This program gives your hospital an opportunity to prioritize
stroke care quality improvement.
Minnesota Stroke Registry Program Manual
Page 8
Original Release: 8/14/12
Updated: 8/14/12
Enrollment Process
1. Get informed about the program.
a. Read this manual.
b. Visit our website: www.mnstrokeregistry.org
c. Call Albert Tsai at (651) 201-5413 or email [email protected] to ask questions.
2. Sign the Charter.
a. Obtain the Minnesota Stroke Registry Program Charter* from
www.mnstrokeregistry.org or contact Albert Tsai at [email protected].
b. Sign and return the Charter. Signatures are requested from the CEO/Administrator or
Chief Medical Officer and primary program contact.
c. The Minnesota Department of Health will contact your program contact to establish a
mutually agreeable date for which you will start submitting data. We will then sign a
final version of the Charter and send you a copy.
3. Get Started!
a. Your stroke program coordinator will be contacted to establish a MSRT account and set
up training.** We will ask you to fill out a contact form so we know who your key staff
are.
b. As soon as you are trained on the MSRT, begin data abstraction on patients starting with
discharges from the agreed-upon date of service.
c. Your program coordinator will be added to our monthly email distribution list to be
informed over our various offerings, conferences, workshops, trainings, and activities.
Welcome aboard!
* The program charter agreement is not a legally binding document. The Minnesota Stroke Registry
Program is completely voluntary program. The charter agreement is used to ensure that both the
hospital and MDH are clear on expectations for participation.
**Special note for hospitals participating in Get With The Guidelines-Stroke : Submit Participating
Hospital Agreement Amendment to Outcome Sciences (Fax: 617-621-1620, Attention: Ms. Elizabeth
Destin). Please note that “Exhibit B-2” on this amendment will be provided by Outcome Sciences.
Outcome Sciences will contact you to schedule a training session before they turn on your “Coverdell
overlay” version of the Patient Management Tool. Contact Outcome Sciences at (888) 526-6700 or
[email protected] for help.
Minnesota Stroke Registry Program Manual
Page 9
Original Release: 8/14/12
Updated: 8/14/12
Performance Measures, Quality Indicators, and Reports
The Minnesota Stroke Registry Program tracks the quality of acute stroke care through the use of
performance measures and quality indicators. Participating hospitals are required to collect data which
are used to calculate these measures and indicators. Hospitals are encouraged to use these measures to
identify their opportunities for improvement and monitor the impact of systems-based changes and
quality improvement interventions.
All measures and indicators described below are available to participating hospitals through real-time
reports. These reports are available to hospitals at no charge through the Minnesota Stroke Registry
Tool (MSRT), our secure web-based abstraction and reporting tool. Participants in the American Heart
Association’s Get With The Guidelines-Stroke program have access to most of these same reports
through the Patient Management Tool™.
CDC Paul Coverdell National Acute Stroke Registry Performance Measures
1. STK-1: VTE Prophylaxis*
2. STK-2: Discharged on Antithrombotic Therapy*
3. STK-3: Anticoagulation Therapy for Atrial Fibrillation/Flutter*
4. STK-4: Thrombolytic Therapy*
5. STK-5: Antithrombotic Therapy By End of Hospital Day 2*
6. STK-6: Discharged on Statin Medication*
7. STK-7: Dysphagia Screening
8. STK-8: Stroke Education*
9. STK-9: Smoking Cessation Counseling
10. STK-10: Assessed for Rehabilitation*
* Stroke National Inpatient Quality Measures, also known as “stroke core measures,” are reportable to Centers for
Medicare and Medicaid (CMS) for the Hospital Inpatient Quality Reporting (IQR) Program beginning in January 2013. The
Hospital IQR Program requires "sub-section (d)" hospitals to submit data for specific quality measures for health conditions
common among people with Medicare, and which typically result in hospitalization. Eligible hospitals that do not
participate in the Hospital IQR program will receive an annual market basket update with a 2.0 percentage point reduction.
Any patient that is coded with an ICD-9 Principal Diagnosis code of ischemic or hemorrhagic stroke must be reported to
CMS (and as long as the other population criteria is met).
Minnesota Stroke Registry – Emergency Stroke Care Indicators
The MSR-ESC Indicators apply to all patients seen in the emergency department, whether they were
transferred or admitted to the hospital.
1.
2.
3.
4.
5.
6.
NIHSS at Initial Evaluation
Dysphagia Screening (eligible patients include ED-only)
Door-to-Imaging Completed <25 Minutes
Door-to-Image Read <45 Minutes
Door-to-Needle <60 Minutes
Thrombolytic Therapy (eligible patients include ED-only)
Minnesota Stroke Registry Program Manual
Page 10
Original Release: 8/14/12
Updated: 8/14/12
Data Abstraction Toolkit
Data Abstraction…At-A-Glance
1. Abstract all stroke and TIA patient cases within three months of transfer or discharge.
2. Use either the MSRT (developed by MDH) or the Patient Management Tool™ (if your hospital
participates in the Get With The Guidelines-Stroke Program).
3. Confirm monthly case counts at least once per quarter in the MSRT.
4. All hospitals participating in the MSR-Coverdell program track must have their charts audited by
MDH once per year.
5. All hospitals participating in the Minnesota Stroke Registry Program who meet abstraction
requirements will also simultaneously be meeting reporting requirements for the Minnesota
Statewide Quality Reporting and Measurement System (SQRMS).
6. All hospitals participating in the MSR-Coverdell program track who meet abstraction
requirements will also meet Joint Commission and CMS stroke core measure abstraction
requirements.
Case Definition
Inclusions:
Patients that meet one or more of these criteria must be abstracted:
1. Patients with a final clinical diagnosis of stroke or TIA:
Ischemic stroke
Intracerebral hemorrhagic stroke
Subarachnoid hemorrhagic stroke
Transient ischemic attack
2. Patients with an ICD-9-CM principal discharge diagnosis code listed in Table 1 below.
3. Patients who receive tPA in the emergency department. Note: this includes those are then
transferred to another hospital. Use ICD-9-CM Procedure Code 99.10 to identify potential cases
and include only if they were treated with thrombolytic therapy for ischemic stroke.
Exclusions:
Patients age 17 or younger on day of arrival.
Optional Exclusions
Hospitals are not required to abstract an eligible patient’s record if s/he meets any of the criteria below.
1.
2.
3.
4.
Patients admitted solely for elective carotid endarterectomy or any revascularization.
Patients enrolled in a clinical trial related directly to stroke care.
Patients who expire in the emergency department.
Patients not admitted nor transferred to another hospital.
Minnesota Stroke Registry Program Manual
Page 11
Original Release: 8/14/12
Updated: 8/14/12
Table 1: ICD-9 CM codes, Minnesota Stroke Registry Case Definition
Code
ICD-9 Diagnosis
HEMORRHAGIC STROKE
430
SUBARACHNOID HEMORRHAGE
431
TJC*
X
INTRACEREBRAL HEMORRHAGE
X
ISCHEMIC STROKE
433.01
OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH CEREBRAL INFARCTION
X
433.10
OCCLUSION AND STENOSIS OF CAROTID ARTERY WITHOUT CEREBRAL INFARCTION
X
433.11
OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL INFARCTION
X
433.21
OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITH CEREBRAL INFARCTION
X
433.31
OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL ARTERIES WITH CEREBRAL INFARCTION
X
433.81
OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION
X
433.91
OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION
X
434.00
CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION
X
434.01
CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION
X
434.11
CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION
X
434.91
CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION
X
436
ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE
X
TRANSIENT ISCHEMIC ATTACK
435
TRANSIENT CEREBRAL ISCHEMIA
435.0
BASILAR ARTERY SYNDROME
435.1
VERTEBRAL ARTERY SYNDROME
435.2
SUBCLAVIAN STEAL SYNDROME
435.3
VERTEBROBASILAR ARTERY SYNDROME
435.8
OTHER SPECIFIED TRANSIENT CEREBRAL ISCHEMIAS
435.9
UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA
Impending cerebrovascular accident
Intermittent cerebral ischemia
Transient ischemic attack [TIA]
STROKE IN PREGNANCY
671.5X
CEREBRAL VENOUS SINUS THROMBOSIS DURING PREGNANCY OR IN THE PUERPERIUM
674.0X
CEREBROVASCULAR COMPLICATIONS OF THE PUERPERIUM
* Codes indicated with an X in the column labeled “TJC” are explicitly listed in the Specifications Manual, Appendix A, Tables 8.1 and 8.2.
Minnesota Stroke Registry Program Manual
Page 12
Original Release: 8/14/12
Updated: 8/14/12
Minnesota Stroke Registry Case Definition
Age 18+?
NO
DO NOT
INCLUDE
YES
INCLUDE
YES
INCLUDE
YES
INCLUDE
8/2/2012
YES
Final Clinical
Diagnosis =
Stroke or TIA
NO
ICD-9-CM
Principal
Diagnosis in
Table 1
NO
Did patient
receive tPA
for stroke?
NO
DO NOT
INCLUDE
Hospitals are allowed to exclude patients from abstraction if they meet any of these criteria:
1. Patient was admitted solely for elective carotid endarterectomy or any revascularization.
2. Patient was enrolled in a clinical trial related directly to stroke care.
3. Patient expired in the emergency department.
4. Patient was not admitted to the hospital nor transferred to another hospital.
Minnesota Stroke Registry Program Manual
Page 13
Original Release: 8/14/12
Updated: 8/14/12
Case Ascertainment
Case ascertainment is defined as the methodology by which patient case records are identified for
inclusion in and data collection for the Minnesota Stroke Registry.
The CDC Paul Coverdell National Acute Stroke Program recommends that hospitals identify cases
“prospectively.” That is, a daily review of emergency department and admission logs is done to look for
new admissions of stroke patients. This is also known as concurrent case identification. However, we
acknowledge that hospitals most often identify cases by querying their medical record systems by ICD-9
codes for patients who have already been discharged from the hospital. Our experience is that it is most
practical to identify cases for inclusion through both methods. Hospitals are expected to utilize two
methods to identify cases for inclusion and abstraction:
1. Review case logs. Case logs should be reviewed from the following sources:
Emergency Department
Hospital Admissions
Neurology Consults
Abstractors should review case logs for patients with an admission or final clinical diagnosis of stroke or
TIA – daily, if possible. If this is not feasible, review the logs as frequently as possible, and systematically
review every day’s log sheets.
2. Obtain report from medical or billing records department of cases with ICD-9 CM principal
diagnosis discharge code for stroke or TIA.
Abstractors should request a report from their medical or billing records departments that lists potential
cases to be abstracted. This should ideally be done weekly if possible, otherwise monthly. Please refer to
Table 1 for the appropriate ICD-9-CM codes.
NOTE: Review case and procedure logs for all patients receiving tPA for stroke treatment.
Abstractors should examine all cases in which tPA was administered for stroke patients, including
transferred patients. These patients, if they are not already discovered through ED or admission logs,
should be included.
Minnesota Stroke Registry Program Manual
Page 14
Original Release: 8/14/12
Updated: 8/14/12
Abstraction Deadlines
Hospitals are expected to abstract patient records according to the following schedule:
Date of Service
January
February
March
April
May
June
July
August
September
October
November
December
Abstraction Deadline
April 30
May 31
June 30
July 31
August 31
September 30
October 31
November 30
December 31
January 31
February 28
March 31
Data Elements
Please see Appendix A, Tables 1 and 2, for a complete list of all data elements collected by program
participants. Table 1 lists all elements required to be collected by MSR-Coverdell hospitals. Table 2 lists
all elements required to be collected by MSR-ESC hospitals.
Dictionary
The Minnesota Stroke Registry Data Dictionary can be found by logging into the user’s secure Minnesota
Stroke Registry Tool (MSRT) account and searching under “Resources.”
For questions, examples, and information about data elements used in stroke core measure reporting,
abstractors should refer to the Specifications Manual for the Stroke National Inpatient Quality
Measures. It can be found at www.qualitynet.org. Mouse-over the “Hospital-Inpatient” tab and select
“Specifications Manual.” Or, click on this link to go directly to this page.
Hospitals using the Patient Management Tool™ as their data collection tool (participants in the
American Heart Association’s Get With The Guidelines-Stroke Program) should refer to the Coding
Instructions for all questions about data elements.
For all abstraction questions, please contact Jacob Zdon at [email protected] or (651) 201-5436.
Minnesota Stroke Registry Program Manual
Page 15
Original Release: 8/14/12
Updated: 8/14/12
Data Submission Options
MSR-Coverdell
There are three data submission options currently available to MSR-Coverdell track hospitals.
1. MSRT-Standard: this is our “regular” web-based tool. It includes only data required by the
program to be submitted.
2. Patient Management Tool™: This web-based tool is provided by Outcome Sciences, Inc. for
participants of the American Heart Association Get With The Guidelines-Stroke Program.
MSR-Emergency Stroke Care (ESC)
1. MSRT-ESC: This module of the MSRT is designed to isolate and require data required for MSRESC track hospitals.
Minnesota Stroke Registry Program Manual
Page 16
Original Release: 8/14/12
Updated: 8/14/12
Minnesota Stroke Registry Tool (MSRT)
This manual only covers basic information about using and navigating through the MSRT. A full training
session is available for new users. Contact Jacob Zdon at [email protected] to schedule a training
session.
Obtain a User Account
After your hospital has enrolled in the program, your stroke program coordinator will be issued a user
account and temporary password.
Administration and Access
The MSRT offers three user access levels.
1. Reports - access to reports only
2. Data Entry - access to reports and data entry
3. Staff Admin - access to reports, data entry, staff maintenance page, data exchange, and other
A primary contact for the program must be identified and will receive the “Staff Admin” access level.
Abstractors and others who should have access to case records may be assigned “Data Entry” level
access. The Reports user access level may be created for other staff that only need access to run and
view reports. These users do not have the ability to add, delete, or modify cases in the system.
Logging in
Go to: https://www.health.state.mn.us/divs/hpcd/mnstrokeregistry/login.cfm
(Bookmark this page. Alternatively, go to www.mnstrokeregistry.org and click on Member Login)
When you first log in, the MSRT will prompt you to change your temporary password.
If you ever forget your password, click on the “Reset Password” button and you will be emailed
instructions on how to set a new password. If you have forgotten your username, contact Jacob Zdon at
[email protected].
Minnesota Stroke Registry Program Manual
Page 17
Original Release: 8/14/12
Updated: 8/14/12
Setting up User Accounts
Users with the “Staff Admin” access level have the ability to create new user accounts for the MSRT. To
create an account, select the “Facility Staff” link under the Facility tab, and select the “Add Staff” button.
Enter information into the following fields: First Name, Last Name, Work Phone, Email, Login (first letter
of first name and entire last name), temporary Password (the password should have a minimum of 8
characters and should include upper case and lower case letters, a number, and a symbol), Security
level, Active field (select “Yes”), Account Suspended Field (select “No), and Assigned facility. Select
“Submit” and provide the login and password to the new user.
Minnesota Stroke Registry Program Manual
Page 18
Original Release: 8/14/12
Updated: 8/14/12
Navigation
The default view of the MSRT is the Case History under the “Facility” tab. Mouse-over the Facility tab
and when you click on the “Case History” link, all of the cases that have been entered for your hospital
will appear. Search for a specific patient ID by using the search field at the top of the page, by advancing
by page using the arrows, or entering the page desired at the bottom of the screen. Sort cases in
whatever manner you wish by selecting the column titles (Patient number, Arrival Date, Admission Date,
Discharge Date, ICD-9 CM Principal Diagnosis Code, or Status) .
Creating a new case
To start a new case record, click on “Add Case” (at the bottom of the page), or mouse-over the Facility
tab and select “Add Case.” To start a case record, you must first enter in a “Patient Identifier.” Please
use a system to create Patient Identifiers that does not use medical record or Social Security numbers. If
you need to change the Patient Identifier, select the “Edit PI” button.
Minnesota Stroke Registry Program Manual
Page 19
Original Release: 8/14/12
Updated: 8/14/12
Users should save their information frequently. A “Save” button is available at the bottom of each page.
Clicking on the “Save and Advance” button both saves and moves the user to the next section. When
selecting the “Save” button, the MSRT will scan the saved data for any errors. If errors are detected, the
MSRT will highlight in red the data element where the error exists, highlight in red the section where the
error exists, and provide a warning that describes the error. To address the error, change the data
element answer that prompted the warning and select “Save”.
Closing a Case
After abstraction for a case has been completed, users may “close” the record. The MSRT will place this
record into “Close Mode,” in which the entire case record is then scanned for any data elements that
have not been answered and are required to be answered. Unanswered data elements that are required
to be answered will be highlighted with a red background as will its section. A record cannot be closed
until required data elements have been answered. After you answer all data elements highlighted in
red, click save and they will no longer be highlighted.
Minnesota Stroke Registry Program Manual
Page 20
Original Release: 8/14/12
Updated: 8/14/12
In the example above, the required Age field is missing. By answering this data element and clicking
“Save,” the system will return a message highlighted in green background that says the record is closed.
Removing a Case
In order to remove a case from the database, you must submit a request by emailing
[email protected] with the patient ID number and reason for removal.
Minnesota Stroke Registry Program Manual
Page 21
Original Release: 8/14/12
Updated: 8/14/12
Special Feature: Patient Care Staff Tab
Information entered into the Staff section of the MSRT case report form can be used to provide targeted
feedback to staff regarding performance and to provide data for provider performance reports. This is
an optional feature.
To set-up the Staff section, select the Patient Care Staff link under the Facility tab. At the top of the
Patient Care Staff page are the “Add Position” and “Add Person” links. These links allow for adding
positions and people to the Staff section. Also displayed are the positions and people available within
the Staff section where editing and removal of those positions and people is possible. If you choose to
remove a position or person, the position or person appears within the removal tables at the bottom of
the page.
Note: Add positions first before adding people
since you will be assigning people to positions.
Access: Users with account type “Staff Admin”
can access the “Patient Care Staff” Maintenance
page AND the “Facility Staff” page. “Data Entry”
account users can only access the “Staff” Tab.
(“Reports” account users cannot access either of
these special pages.)
Minnesota Stroke Registry Program Manual
Page 22
Original Release: 8/14/12
Updated: 8/14/12
Resources
The Resources pages within the MSRT include information about data collection, quality improvement
resources, presentations from program conference calls, handouts from the abstraction workshop, and
information about the Minnesota Statewide Quality Reporting and Measurement System (SQRMS). To
access this information select the Resources link under the Resources tab.
The Minnesota Stroke Registry Data Dictionary is also found under the Resources tab. You can find
information about each data element by going to the MSRT Dictionary section where the element
appears. Click on the categories to open and close additional information.
-
Description
Options
Notes for Abstraction
-
Examples
Rationale
Suggested Data Sources
Below is a screenshot of the “Age” variable. (The additional information under “Rationale” and
“Suggested Data Sources” are still hidden from view in this screenshot.)
Minnesota Stroke Registry Program Manual
Page 23
Original Release: 8/14/12
Updated: 8/14/12
Reports
The MSRT provides a wide range of powerful reports for hospitals. Reports may be generated at any
time in multiple formats: bar charts, line charts, scatter charts, or tables only. Data can be reported by
month, quarter, year, or over any range of dates. Reports can be filtered by gender, diagnosis, and other
variables. In addition, you can compare your hospital’s performance on most measures with the
aggregate performance of different categories of hospitals (e.g., by size, geographic location) in the
state and nationally.
1. To run a report, click on the Reports tab.
2. Select a time period interval (monthly, quarterly, annual, or another date range) and a date
range. Next select a Report Type. A variety of sets of measures and indicators are available.
Once you select a Report Type, you must select “Report Name” from the drop-down menu.
3. A “Report Format” can next be selected (on screen, a PDF, or outputting a comma delimited
file).
4. The type of chart (horizontal bar, vertical bar, scatter chart, or tables only)
5. Finally, you can output your data in various ways. Filter the reports based on various variables;
Compare your hospital with other hospitals; output a listing all of the patients who “failed” to
meet a measure.
Note: An additional series of quality indicator reports have been created in the MSRT for programs to
use. These are available only to those that abstract optional data elements on their cases. Please note
that these reports are provided in order to help your hospital monitor your quality improvement
processes, and the reports in these “quality indicators” are NOT reported to CDC or CMS. Please see
Appendix B for a listing of these reports. For more information, please contact our program staff for
assistance.
Minnesota Stroke Registry Program Manual
Page 24
Original Release: 8/14/12
Updated: 8/14/12
Data Exchange
Data Exports: To export raw data from the MSRT database, select the Data Export link under the Data
Exchange tab. Enter the start and end dates, indicate whether cases should be selected by Arrival Date
or Discharge Date, and select “Export Data.” A dictionary describing the data element names and values
is available upon request.
If your hospital uses Premier as its CMS vendor, the MSRT provides an export feature that meets
Premier format requirements. To export data in the Premier format, select the “Export CMS” link under
the Data Exchange tab, enter your hospital’s company code, the start and end dates, whether the export
should include closed records only, and select “Export”.
Data Imports: Hospitals are also able to import data into the MSRT database from other sources. Most
commonly, these are stroke core measure data that have been entered (and/or automatically extracted
from the electronic medical record) into a third-party vendor for CMS/TJC core measure reporting. Files
to be imported must meet specifications established by the MSRT. Hospitals may request assistance in
importing data by contacting our program staff.
Case Report Forms
The Minnesota Stroke Registry Program has a series of paper Case Report Forms (CRF) that may be used
in abstracting a patient record. The CRF allows the abstractor to first write down the answers for
required data elements onto a paper form before transferring these data into the web-based data
collection tool, the MSRT. These forms are available for download from the MSRT on the Resources Tab.
Minnesota Stroke Registry Program Manual
Page 25
Original Release: 8/14/12
Updated: 8/14/12
Patient Management Tool™
Background: Get With The Guidelines Program
The Get With The Guidelines-Stroke quality improvement program is provided by the American Heart
Association/American Stroke Association. This program provides hospitals with guideline information,
access to clinical decision support and reports. To learn more about Get With The Guidelines-Stroke ,
click on this link (electronic document users). The CDC Paul Coverdell National Acute Stroke Program
and Get With The Guidelines-Stroke have aligned their programs to minimize duplication and provide
hospitals a wider array of programmatic and technical support.
Registration and Training
To join the Get With The Guidelines-Stroke Program, please contact Ms. Jeanne Rash at
[email protected]. After you register, submit your signed contract with Outcome Sciences, you will
be contacted by Outcome to schedule a training session for the Patient Management Tool™ (PMT).
To join the Minnesota Stroke Registry Program, you must sign an amendment to your contract with
Outcome Sciences. This amendment authorizes the Outcome Science to release your data to MDH as
part of this program. After your signed amendment is received by Outcome Sciences, they will contact
you to train your staff on the unique features of the “Coverdell Overlay” of the Patient Management
Tool™. This version of the Patient Management Tool™ will be turned on after you complete this webbased training session. To contact Outcome sciences, email [email protected] or call (888) 526-6700.
Data submission
Hospitals use the PMT to enter data on their stroke patients. The abstractor may directly enter data into
the PMT, or record data on the paper case report form first, then enter the data later into the PMT.
On the first Monday of each month, MDH downloads the hospital’s stroke patient case data from the
Outcome Sciences database and imports these data into the Minnesota Stroke Registry database. These
data are accessible to the hospital through their Minnesota Stroke Registry Tool (MSRT) user account.
Removing a Case
To remove a case from the Outcome Sciences database, you must submit a request to Outcome. You
must also submit a request to the Minnesota Department of Health to remove the case from the
Minnesota Stroke Registry Program database. To do so, you must email [email protected]
with the patient ID case number of the case that you removed from the GWTG/Outcome database.
Reports
Hospitals participating in the Get With The Guidelines-Stroke program typically will utilize the reports
available through the Patient Management Tool™. However, hospitals may also access the reports that
are available through the Minnesota Stroke Registry Tool (MSRT).
Resources and Information
For technical help regarding data submission, contact the [email protected]. For help regarding
data definitions or other clinical abstraction questions, contact Jeanne Rash at [email protected].
Minnesota Stroke Registry Program Manual
Page 26
Original Release: 8/14/12
Updated: 8/14/12
Case Count Confirmation
Hospitals must confirm the monthly case counts of all of their abstracted patient cases on a quarterly
basis. In order to do so, each quarter’s end (March 31, June 30, September 30, and December 31) will
signify formal abstraction deadlines. One week prior to the end of each quarter, the primary data
abstraction contact person for each hospital will receive an email reminder to confirm cases through the
end of the previous quarter. In order to keep up with our program expectation that hospitals keep as
current as possible on abstraction, hospitals should aim to confirm their case counts monthly (that is,
NOT wait until the end of each quarter).
Notification Process: Two weeks following each quarter’s end, all hospitals which have not confirmed
cases through the previous quarter will be reminded again via email to confirm their cases numbers.
After two more weeks (one month past the quarterly deadline), if the hospital has not confirmed its
monthly case numbers through the end of the previous quarter, it will be assumed that you have not
abstracted all of your cases through the previous quarter. A email will be sent to remind your facility of
your abstraction requirements.
Steps:
1. Log into the Minnesota Stroke Registry Tool:
https://www.health.state.mn.us/divs/hpcd/mnstrokeregistry/login.cfm
If you have forgotten your login username, please contact [email protected]. If you have
forgotten your password, you may enter your username and click the “Reset Password” button
and you will be immediately emailed instructions for resetting your password.
2. From any page, you may move your mouse over the “Facility” menu tab. A drop-down menu will
appear. Select the “Case Confirmation” link.
Minnesota Stroke Registry Program Manual
Page 27
Original Release: 8/14/12
Updated: 8/14/12
This screen should appear:
3. From the drop-down menu labeled “Choose Year”, select the year of discharges for which you
are confirming case numbers.
4. The months for that year will appear. Below each month is the number of cases that the MSRT
has in the database for that month. Note: A case will be counted if its Patient Identifier and
Discharge Date have been saved within the MSRT database. Hospitals participating in Get With
The Guidelines-Stroke : on the first Monday of each month, the Minnesota Department of
Health downloads the hospital’s stroke patient case data from the Outcome Sciences database
and imports these data into the Minnesota Stroke Registry database.
To confirm the case number for a month, click on “Confirm.” This button will change to the word
“Confirmed” with a green-colored background. This will lock the number that appears for that
month.
5. If you have previously confirmed a month but discover later that the “confirmed” case number
is incorrect (for instance, it does not match your own log, as you added a case for that month
after you had confirmed it before), you may "unconfirm" that month. You will be asked if you
are sure that you want to unconfirm the case count. Click “Yes” to unconfirm. The most current
(new) case count number will then appear for that month, and then you can re-confirm a that
month.
Minnesota Stroke Registry Program Manual
Page 28
Original Release: 8/14/12
Updated: 8/14/12
Chart auditing
The collection of high quality data using consistent methods over time is essential to the success of the
Minnesota Stroke Registry Program. The integrity of all the results and outcomes from the data analyses
depend on the accuracy and consistency of the data collected. Achieving data accuracy is made more
difficult due to the all-encompassing nature of the registry itself. The Minnesota Stroke Registry Program
includes numerous hospitals, all differing in size, experience, record systems, staffing, stroke volumes,
and other factors that make obtaining consistent data even more challenging. In addition, the
interpretation and abstraction of the data elements themselves can lead to inaccuracies and
inconsistencies in the data. It can be very difficult to define and interpret all the limitless situations that
can arise in patient care with the limited data dictionary. Therefore, it is important to have a protocol to
ensure data quality. This section describes the methods used for addressing data quality in the
Minnesota Stroke Registry Program.
Overview
The Quality Assurance (QA) Coordinator conducts a medical record audit once per year for hospitals
participating in the MSR-Coverdell track. The cases chosen for the audit are randomly selected, with a
focus on cases eligible to receive IV-tPA and with discharge dates falling within the last half of the audit
period. The QA Coordinator abstracts the selected cases and enters data into the MSR database using
the Minnesota Stroke Registry Tool. The entered cases are then compared to the originally-abstracted
records for inter-reliability agreement. Any potential discrepancies are assessed to determine the
reasons for those discrepancies. Abstraction training will address those reasons to minimize
discrepancies for future abstraction.
Auditing
1. Hospitals will be audited every 12 months. Auditing of hospitals will occur every year beginning
April 1. Our expectation is that hospitals will finish entering cases for the previous year by this
date. Example: when the auditing process begins April 1, 2013, hospitals should have finished
entering cases for through December 31, 2012.
2. Timeline of Audits:
Audit Period
January 2012 - December 2012
January 2013 - December 2013
January 2014 - December 2014
January 2015 - December 2015
Audit Date
April 2013
April 2014
April 2015
April 2016
3. When a hospital has finished abstracting their cases for the year, the QA coordinator will create
an auditing sample in the MSRT. The auditing sample will appear as a case list consisting of the
Patient ID, Arrival Date, Discharge Date, and ICD-9 Discharge Diagnosis with the hospital name
and auditing period at the top. At the bottom of the list you will see the date of when the list
was created.
Minnesota Stroke Registry Program Manual
Page 29
Original Release: 8/14/12
Updated: 8/14/12
4. The initial eligibility for a case to be selected for auditing is determined by matching the stroke
related ICD-9-CM Discharge Diagnosis with the ICD-9-CM diagnosis codes in Table1 (page 11).
5. For hospitals with annual stroke caseloads below 200, the audit sample total is five (5) cases. For
hospitals with annual case loads of 200 or greater, the audit sample total is twenty (20) cases.
6. The audit sample consists of two sub-samples. The first sub-sample consists of a random sample
of cases eligible for IV-tPA therapy. The second sub-sample consists of a random sample of cases
from the last half of the audit year.
7. The QA Coordinator will email a list of the audit sample case IDs to the appropriate hospital
contact (e.g., abstractor).
8. The QA Coordinator will conduct the auditing by one of three ways:
a. Traveling to the hospital and auditing the electronic and/or paper charts.
b. Auditing charts remotely through an internet portal.
c. Auditing paper charts obtained by mail/carrier or email.
9. The QA Coordinator must meet any EMR access requirements for all hospitals prior to auditing.
The expectation is that the QA Coordinator will be able to view the same information as the
hospital-based abstractors.
10. The QA Coordinator has the choice of abstracting data directly into the Minnesota Stroke
Registry Tool (MSRT) using an internet connection or abstracting data first onto a case report
form (CRF). If the QA coordinator uses the CRF, the coordinator will enter the data into the
MSRT upon return to the Minnesota Department of Health offices. These CRFs will then be
shredded and disposed according to MDH policy regarding protected health information.
11. For hospitals that send paper copies of medical charts to be audited, the information within
those medical charts will be managed in accordance with the Minnesota Department of Health
Data Practice Manual (October 2005). When not being audited, the medical chart copies will be
kept in a locked file cabinet on a secure office floor where only MDH employees can enter. The
medical chart copies will be destroyed immediately once the QA coordinator has finished
auditing them.
Analysis and Reporting
1. Statistical Analysis Software (SAS 9.2, Cary, NC) is used to measure the agreement between the
hospital’s abstracted answers and the auditor’s abstracted answers. A Kappa coefficient is used
to measure the inter-reliability of categorical data elements. A Kappa coefficient of less than 0.4
is considered an unacceptable level of agreement. For both categorical and continuous data
elements, a percentage agreement is calculated. A percent agreement of less than 60 percent is
considered unacceptable for continuous data elements.
Minnesota Stroke Registry Program Manual
Page 30
Original Release: 8/14/12
Updated: 8/14/12
2. Once the analysis is complete for a hospital, a report is created. The report consists of a
summary of the data elements and their analysis scores, a section presenting the case
discrepancies of those data elements where a meaningful difference exists between the
hospital’s and auditor’s abstraction answers, and a section summarizing the conclusions made
during the audit report meeting pertaining to why those differences occurred.
3. The auditing report and accompanying cover letter will be sent to the hospital within two weeks
after the site visit. The letter will describe how the analysis was conducted and a request to
schedule a meeting to discuss the report.
4. At the meeting, the QA Coordinator will review and discuss reasons for the differences between
the auditor’s and hospital’s answers, and address other current data abstraction issues. This
meeting will occur either via telephone or in-person.
5. Within one week of the meeting’s conclusion, a summary of the meeting will be sent to
attendees.
New Hospitals
1. Once a new hospital has entered three (3) cases into the MSRT, the QA coordinator will audit
those cases.
2. The QA coordinator starts the audit within a month after the discharge date of the third case.
3. No analysis will be done for the audit. Instead, the QA Coordinator will set up a meeting with the
abstractors of the new hospital and will go over the answers for each case for each data element
and discuss any discrepancies that occur. The objective of this meeting is to identify any
meaningful discrepancies (i.e., misinterpretation of a data element by the new abstractor) and
to prevent such discrepancies from happening in the future.
4. It is possible for these first three cases to be included in the annual auditing sample. If overlap
occurs, the auditor abstracts only those cases that have not been previously audited.
New Abstractors
1. When a new abstractor begins abstracting at a currently participating hospital, the QA
coordinator will audit the first 3 charts the new abstractor abstracts. The primary hospital
contact is responsible for informing the MSR staff about new abstractors.
2. The QA coordinator will start the audit within a month after the discharge date of the third case.
Minnesota Stroke Registry Program Manual
Page 31
Original Release: 8/14/12
Updated: 8/14/12
3. No analysis will be done for the audit. Instead, the QA Coordinator will set up a meeting with the
new abstractor and will go over each data element for each case. The objective of the meeting is
to identify any meaningful discrepancies (i.e., misinterpretation of a data element by the new
abstractor) that may have occurred and to prevent such discrepancies from happening again.
4. It is possible for these first three cases to be included in the annual auditing sample. If overlap
occurs, the auditor abstracts only those cases that have not been previously audited.
Minnesota Stroke Registry Program Manual
Page 32
Original Release: 8/14/12
Updated: 8/14/12
Appendix A: Data Elements
Table 1. MSR-Coverdell: Required Data Elements
Hospitals participating in Track 1 MSR-Coverdell must collect data on the stroke core measures and CDC quality
indicators. These are reflected in Table 1, sections A and B. A total of 40 data elements are required in order to
calculate stroke core measures. An additional 34 elements are required CDC quality indicator data elements, for a
grand total of 74 required data elements.
A. Stroke Core Measures Data Elements
Beginning with January 1, 2013 dates of service, Prospective Payment System (PPS) hospitals will be required to
report stroke core measure data to the Centers for Medicare and Medicaid Services (CMS). The Joint Commission
also requires reporting of these same measures of hospitals certified as Primary Stroke Centers. (Source:
Specifications Manual Version 4.1 http://www.qualitynet.org) The Minnesota Stroke Registry Program offers use of a
free tool that can be used for core measure data collection and reporting.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
Anticoagulation Therapy Prescribed At Discharge
Antithrombotic Therapy Administered by End of Hospital Day 2
Antithrombotic Therapy Prescribed At Discharge
Arrival Date
Arrival Time
Assessed for Rehabilitation Services
Atrial Fibrillation/Flutter
Comfort Measures Only
Date Last Known Well
Discharge Disposition
ED Patient
Education Addresses Activation of Emergency Medical System
Education Addresses Follow-up After Discharge
Education Addresses Medications Prescribed at Discharge
Education Addresses Risk Factors For Stroke
Education Addresses Warning Signs and Symptoms of Stroke
IV OR IA Thrombolytic (t-PA) Therapy Administered at This Hospital or Within 24 Hours Prior to Arrival
IV Thrombolytic Initiation
IV Thrombolytic Initiation Date
IV Thrombolytic Initiation Time
Last Known Well
LDL-c Greater Than or Equal to 100 mg/dL
LDL-c Measured Within the First 48 Hours or 30 Days Prior to Hospital Arrival
Pre-Arrival Lipid-Lowering Agent
Reason for No VTE Prophylaxis – Hospital Admission
Reason For Not Administering Antithrombotic Therapy By End of Hospital Day 2
Reason For Not Initiating IV Thrombolytic
Reason For Not Prescribing Anticoagulation Therapy at Discharge
Reason For Not Prescribing Statin Medication At Discharge
Time Last known Well
VTE Prophylaxis
Minnesota Stroke Registry Program Manual
Page 33
Original Release: 8/14/12
Updated: 8/14/12
32.
33.
34.
35.
36.
37.
38.
39.
40.
VTE Prophylaxis Date
Birthdate (the MSR collects Age)*
Sex*
Race*
Hispanic Ethnicity (Ethnicity)*
Payment Source (Health Insurance)*
Admission Date*
Discharge Date*
ICD-9-CM Principal Diagnosis Code*
*Collected for all core measures.
Note: Clinical Trial, Elective Carotid Intervention, and ICD-9 Other Diagnosis Codes are required core measure data
elements which are considered optional for Minnesota Stroke Registry Program hospitals (see Table 3).
B. CDC Paul Coverdell National Acute Stroke Program Data Elements
The CDC Paul Coverdell National Acute Stroke Program collects stroke quality indicator data additional to the
stroke core measures. These data are aligned with data required by the Get With The Guidelines-Stroke™ program.
We have listed them here in the order they appear in the Minnesota Stroke Registry Tool Case Report Form.
Patient Information
1.
2.
3.
4.
5.
Final clinical diagnosis related to stroke
Was patient placed on observation status?
Was patient admitted to this hospital?
If discharged to other health care facility, where to?
How patient arrived at your hospital
Diagnosis and Treatment
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Had stroke symptoms resolved at time of presentation?
Was NIHSS performed?
Initial NIH stroke scale score
Was patient NPO throughout the entire hospital stay?
Dysphagia screening completed? (STK-7)
Brain imaging completed at your hospital for this episode of care?
Date Brain Imaging Completed
Time Brain Imaging Completed
Date of discovery of stroke symptoms?
Time of discovery of stroke symptoms?
If IV tPA was initiated greater than 60 minutes after hospital arrival, were eligibility or medical reason(s)
documented as the cause for delay?
IV tPA given at an outside hospital?
IA catheter-based reperfusion at this hospital?
Complications of thrombolytic therapy
If bleeding complications occur in patient transferred after IV tPA, when?
Minnesota Stroke Registry Program Manual
Page 34
Original Release: 8/14/12
Updated: 8/14/12
History
21.
22.
23.
24.
25.
26.
Patient location when stroke symptoms discovered
Previously known medical history of: (Check all that apply)
Ambulatory status prior to current event
Medications prior to admission: Cholesterol reducer
Medications prior to admission: Antihypertensive
Medications prior to admission: Antiplatelet or Anticoagulant Medication(s)
Admission and Inpatient Information
27. Was DVT or PE documented?
28. Treatment for Hospital-Acquired Pneumonia
Discharge Information
29.
30.
31.
32.
33.
34.
Cholesterol-reducing treatment at discharge
Statin medication dosage
Antihypertensive treatment at discharge
Modified Rankin Scale at discharge
Modified Rankin Scale at discharge Total Score
Anti-Smoking treatment (previously known as STK-9)
Minnesota Stroke Registry Program Manual
Page 35
Original Release: 8/14/12
Updated: 8/14/12
Table 2. MSR-Emergency Stroke Care: Required Data Elements
Hospitals participating in Track 2 MSR-ESC must collect data for the Minnesota Stroke Registry Emergency Stroke
Care Indicators. The 31 data elements in this table are used to calculate these indicators.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
Arrival Date
Arrival Time
Discharge Date
Age
Sex
Final clinical diagnosis related to stroke
ICD-9-CM Principal Diagnosis Code
Discharge Disposition
Comfort Measures Only
Payment Source (Health Insurance)
Race
Hispanic Ethnicity (Ethnicity)
ED Patient
Was patient placed on observation status?
Was patient admitted to this hospital?
If discharged to other health care facility, where to?
How patient arrived at your hospital
Initial NIH stroke scale score
Dysphagia screening completed? (STK-7)
Was patient NPO throughout the entire hospital stay?
Brain imaging completed at your hospital for this episode of care?
Date Brain Imaging Completed
Time Brain Imaging Completed
Date image read
Time image read
Date Last Known Well
Time Last known Well
IV Thrombolytic Initiation (STK-4)
IV Thrombolytic Initiation Date
IV Thrombolytic Initiation Time
Reason For Not Initiating IV Thrombolytic
Minnesota Stroke Registry Program Manual
Page 36
Original Release: 8/14/12
Updated: 8/14/12
Table 3. Optional Data Elements
The Minnesota Stroke Registry Tool and the GWTG-Stroke Patient Management Tool™ have both been designed
to offer hospitals the choice to optionally abstract a number of data elements. Hospitals may run quality indicator
reports based on these data in the MSRT. Benchmarking is not available for on these indicators because not all
hospitals collect these data. These elements are available to either MSR-Coverdell or MSR-ESC hospitals.
Initial Evaluation
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
EMS pre-notification
Was any of the following documented by EMS? (check all that apply)
Were the following pre-notified of an incoming stroke patient? (check all that apply)
Where patient first received care at your hospital
Admission Diagnosis
Glasgow Coma Scale in ICH patients
Total GCS score
Total cholesterol
HgbA1C
INR
Initial exam findings
Stroke code declared
Initial brain imaging findings
Dysphagia screening results
Date CBC with platelets drawn
Time CBC with platelets drawn
Date CBC with platelets received
Time CBC with platelets received
Date electrolyte panel with Creatinine drawn
Time electrolyte panel with Creatinine drawn
Date electrolyte panel with Creatinine received
Time electrolyte panel with Creatinine received
Date INR was drawn
Time INR was drawn
Date INR result received
Time INR result received
Date EKG ordered
Time EKG ordered
Treatment
29.
30.
31.
32.
33.
34.
35.
36.
37.
Was IV access X2 established prior to tPA?
Was tPA protocol used?
Was tPA bolus administered?
Was tPA infusion administered?
Was weight of patient documented?
Was Foley catheter started BEFORE tPA administered?
IA tPA at outside hospital
Date of IA reperfusion at this hospital
Time of IA reperfusion at this hospital
Minnesota Stroke Registry Program Manual
Page 37
Original Release: 8/14/12
Updated: 8/14/12
Inpatient Care
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
Elective Carotid Intervention*
Clinical Trial *
Unit type
Stroke order set used
Was patient ambulating the day of admission or day after admission?
Was patient treated for a urinary tract infection (UTI) during this admission?
If patient was treated for a UTI, did the patient have a Foley catheter during this admission?
Was NIH Stroke Scale performed at Discharge?
Total NIHSS Score at discharge
Ambulatory status at discharge
Was patient referred to rehab services following discharge?
Was patient ineligible to receive rehab services? (symptoms resolved, poor prognosis, unable to tolerate)
ICD-9 discharge diagnosis related to stroke
ICD-9-CM Other Diagnosis Code*
* Stroke core measure data elements
Minnesota Stroke Registry Program Manual
Page 38
Original Release: 8/14/12
Updated: 8/14/12
Appendix B: Minnesota Stroke Registry Quality Indicators (Optional)
The Minnesota Stroke Registry Program provides analysis support to assist hospitals in targeting process
improvement efforts for acute stroke/TIA care. Most of the current stroke performance measures apply
only to patients who are admitted. Several hospitals, however, do not typically admit most of their
patients, and yet should be providing quality care in the acute phase of treatment. Therefore, we
developed and compiled a set of quality measures that apply specifically to the pre-hospital and acute
phase of diagnosis, stabilization and immediate treatment – whether or not the patient is admitted or
transferred. Reports on these measures are available to all MSRT users in the Reports section.
Pre-Hospital Reports
1. Last Known Well to Arrival
2. Patient Population and Arrival
3. EMS Pre-Notification
ED Care Quality Reports
1. Documentation of Last Known Well
2. Documentation: NIHSS Performed*
3. Door-to-Imaging Times*
4. Door-to-Needle Times
5. Last Known Well to Needle times
6. Reasons for non-treatment with thrombolytic therapy
7. Destination of non-admitted patients
* MDH Statewide Quality Reporting and Measurement System indicators
ED/Inpatient Care Quality Indicator Reports
1. Case Tally by discharge diagnosis
2. NPO through hospital stay
3. ED results of dysphagia screen
Inpatient Care Quality Indicator Reports
1. Inpatient results of dysphagia screen
2. Dysphagia screen among patients treated for pneumonia
3. Dysphagia screen results among patients treated for pneumonia
Minnesota Stroke Registry Emergency Care Indicators
1. EMS Documentation
2. Hospital Staff Pre-notification
3. Door-to-Image Read Time
4. Door-to-Lab Drawn Times
5. Door-to Lab Received Times
6. Door-to-EKG Performed Times
7. Thrombolytic Therapy Protocol Adherence
Minnesota Stroke Registry Program Manual
Page 39
Original Release: 8/14/12
Updated: 8/14/12
Appendix C: Participant Checklist












Identify a stroke program coordinator
Sign and return the charter agreement to MDH
Complete and return contact form to MDH
Obtain MSRT user account
Get trained on data abstraction
GWTG-Stroke hospitals only:
o Enroll in GWTG-Stroke
o Submit participating hospital amendment to Outcome Sciences
o Get trained on PMT (Coverdell overlay)
Abstract your stroke patient data within three months of discharge
Confirm your monthly case counts once per quarter
Convene multi-disciplinary hospital stroke committee
Develop a quality improvement plan
Implement your quality improvement plan (one per year minimum)
Host a hospital stroke capacity assessment (once per year)
Optional Offerings
 Attend quarterly program teleconferences (strongly encouraged)
 Ask MDH for data analysis assistance
 Participate in a performance improvement collaborative
 Attend the annual abstraction workshop
 Attend regional stroke conferences
 Attend the annual statewide stroke conference
Minnesota Stroke Registry Program Manual
Page 40
Original Release: 8/14/12
Updated: 8/14/12
Contact Information
Principal Investigator/Program Director
Albert W. Tsai, PhD, MPH
[email protected]
(651) 201-5413
Web: www.mnstrokeregistry.org
Administrative Support
Jenny Patrin
[email protected]
(651) 201-5412
Co-Principal Investigator/Epidemiologist
Jim Peacock, PhD, MPH
[email protected]
(651) 201-5405
Fax: (651) 201-5800
Mailing Address
P.O. Box 64882
St. Paul, MN 55164-0882
Quality Assurance Coordinator
Jacob Zdon, MPH
[email protected]
(651) 201-5436
Street/Delivery Address
85 East 7th Place, Suite 200
St. Paul, MN 55101
Quality Improvement Nurse Specialist
Mary Jo Mehelich, RN
[email protected]
(651) 201-5419
Applications Programmer
Curtis Fraser, MS
[email protected]
(651) 201-5477
Clinical Consultant
Kamakshi Lakshminarayan, MD, PhD
[email protected]
(612) 624-9492
Registry Consultant
Russell Luepker, MD, MS
[email protected]
(612) 624-6362
Minnesota Stroke Registry Program Manual
Page 41
Original Release: 8/14/12
Updated: 8/14/12