*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 pulmonary edema. Hemphill et al Performance Measures for ICH e253 Appendix. Continued 4. 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 Denominator Included patients: Patients with ICH admitted to an acute care hospital within 24 h of initial symptom identification Excluded patients: <18 y of age Length of stay >120 d Clear documentation for comfort care/palliative care measures established before hospital arrival Period of Assessment Day of hospital admission to hospital Sources of Data Prospective flowsheet, retrospective medical record review, electronic medical record Rationale Patients with ICH are frequently medically and neurologically unstable particularly at the time of initial presentation. 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 for Recommendation From the 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage Initial monitoring and management of patients with ICH should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise (Class I; Level of Evidence B). 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 physician and nursing neuroscience acute care expertise Challenges to Implementation Verification of physician and nursing neuroscience care expertise Measure would require hospitals that do not have such an intensive care unit or dedicated stroke unit to transfer the patient with ICH from the ED to a hospital that has this type of intensive care unit or stroke unit. 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 staff and licensed independent practitioners with the expertise and experience to provide neuro-critical care 24 hours a day, 7 days a week. AHA indicates American Heart Association; ASA, American Stroke Association; ED, emergency department; ICH, intracerebral hemorrhage; and TJC, The Joint Commission. Appendix. Continued 5. Dysphagia Screening Within 24 h: Percentage of patients 18 y of age with a diagnosis of ICH for whom there is documentation that a dysphagia screening was performed within 24 h of admission using a dysphagia screening tool approved by the institution in which the patient is receiving care Numerator Patients for whom there is documentation that a dysphagia screening was performed within 24 h of admission using a dysphagia screening tool approved by the institution in which the patient is receiving care* Denominator Included patients: All patients 18 y of age with a diagnosis of ICH Excluded patients: <18 y of age Length of stay >120 d Enrolled in a clinical trial related to stroke that would affect dysphagia screening Discharged before 24 h Documented reason that dysphagia screening was not indicated. Reasons could include coma, intubation, or that the patient was entirely dependent on enteral feeding (without oral intake of food, liquids, or medications) before hospitalization as a result of a chronic medical condition. Period of Assessment Within 24 h of hospital admission Sources of Data Prospective flowsheet, retrospective medical record review, electronic medical record Rationale Dysphagia is present in up to 67% of patients with acute stroke, and of these, almost 50% have aspiration, a prerequisite for aspiration pneumonia. Up to one third of patients who aspirate develop pneumonia. Pneumonia is a serious complication of stroke and is associated with increased mortality. Several studies have demonstrated a reduction in pneumonia after institutional implementation of dysphagia screening protocols but without randomized control groups. Several swallow screening methods have been published in the literature, each with benefits and limitations, without sufficient evidence to recommend a single consensus method. Source for Recommendation From the 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage A formal screening procedure for dysphagia should be performed in all patients before the initiation of oral intake to reduce the risk of pneumonia (Class I; Level of Evidence B). Method of Reporting Per patient: documentation of whether the patient received a dysphagia screen within 24 h of admission Per patient population: percentage of patients who received a dysphagia screen within 24 h of admission Challenges to Implementation Documentation of timing of dysphagia screen may be difficult to locate in chart review. Requires that institutional dysphagia screening protocols be developed and that adherence to these protocols can be abstracted from the chart. Analogous Measures Endorsed by Other Organizations This measure is identical to the AHA/ASA Ischemic Stroke Performance Measure 11. Analogous measures endorsed or used by NQF (No. 0243), AHA GWTG Stroke, CDC PCNASP, and AMA PCPI. AHA indicates American Heart Association; AMA, American Medical Association; ASA, American Stroke Association; CDC, Centers for Disease Control and Prevention; GWTG Stroke, Get With The Guidelines Stroke; ICH, intracerebral hemorrhage; NQF, National Quality Forum; PCNASP, Paul Coverdell National Acute Stroke program; and PCPI, Physician Consortium for Performance Improvement. *Dysphagia screening may consist of a structured bedside swallowing screen administered by nursing staff, bedside swallow evaluation by a speech-language pathologist, videofluoroscopic swallow evaluation, fiberoptic endoscopic evaluation of swallowing, or other method approved by local institutional protocol. Hemphill et al Performance Measures for ICH e255 Appendix. Continued 6. Passed Dysphagia Screen Before First Oral Intake of Fluids, Nutrition, or Medications: Percentage of patients 18 y of age with a diagnosis of ICH who were documented to have passed the most recent dysphagia screen before oral intake Numerator Included patients: Patients who were documented to have passed* the most recent dysphagia screen before oral intake of fluids, nutrition, or medications Excluded patients: Patients whose first oral intake was not consistent with the recommendations of the most recent dysphagia screen (eg, a patient was provided thin liquids, although the recommendation was for thickened liquids) Denominator Included patients: All patients 18 y of age with a diagnosis of ICH who received oral nutrition, fluids, or medication during the hospital stay Excluded patients: Patients who remained nil per os during the entire hospital stay <18 y of age Length of stay >120 d Enrolled in a clinical trial related to stroke that would affect dysphagia screening Period of Assessment Once during each hospital stay Sources of Data Prospective flowsheet, retrospective medical record review, electronic medical record Rationale Dysphagia is present in up to 67% of patients with acute stroke, and of these, almost 50% have aspiration, a prerequisite for aspiration pneumonia. Up to one third of patients who aspirate develop pneumonia. Pneumonia is a serious complication of stroke and is associated with increased mortality. Several studies have demonstrated a reduction in pneumonia after institutional implementation of dysphagia screening protocols but without randomized control groups. Several swallow screening methods have been published in the literature, each with benefits and limitations, without sufficient evidence to recommend a single consensus method. Source for Recommendation From the 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage A formal screening procedure for dysphagia should be performed in all patients before the initiation of oral intake to reduce the risk of pneumonia (Class I; Level of Evidence B). Method of Reporting Per patient: documentation of whether the patient who received oral intake had passed the most recent dysphagia screen before oral intake Per patient population: percentage of patients who received oral intake and passed the most recent dysphagia screen before oral intake Challenges to Implementation Documentation of timing of dysphagia screen in relation to oral intake may be difficult to locate in chart review. Analogous Measures Endorsed by Other Organizations This measure is identical to the AHA/ASA Ischemic Stroke Performance Measure 12. Analogous measures endorsed or used by NQF (No. 0243), AHA GWTG-Stroke, CDC PCNASP, and AMA PCPI. However, a key difference is that, in contrast to those measures, the AHA/ASA measure requires not only that a dysphagia screen has been administered before oral intake but also that the screen must have been passed, with adoption of an appropriate diet based on the screen results. AHA indicates American Heart Association; AMA, American Medical Association; ASA, American Stroke Association; CDC, Centers for Disease Control and Prevention; GWTG Stroke, Get With The Guidelines Stroke; ICH, intracerebral hemorrhage; NQF, National Quality Forum; PCNASP, Paul Coverdell National Acute Stroke program; and PCPI, Physician Consortium for Performance Improvement. * Passed indicates that an oral dysphagia screening protocol was performed according to institutional protocol and that the results of the screen indicated that oral intake, with or without modifications or restrictions (eg, for consistency of liquids or solid food, or supervision during oral intake), was recommended. In cases in which the most recent screening before first oral intake recommended a modified diet or restrictions, the first oral intake should have been consistent with the recommended modifications; if the first oral intake was not consistent with the recommended dietary modification (eg, the patient was provided thin liquids, although the recommendation was for thickened liquids), then the patient should be excluded from the numerator. The methods for dysphagia assessment and recommendations should be based on an institutional protocol and may include some combination of a structured bedside swallowing screen administered by nursing staff, bedside swallow evaluation by a speech-language pathologist, videofluoroscopic swallow evaluation, fiberoptic endoscopic evaluation of swallowing, consultation with speech- language pathologist or other specialist, or other method approved by local institutional protocol. Appendix. Continued 7. Long-Term Blood Pressure Treatment Initiation: Percentage of patients with ICH who are prescribed an oral or transdermal antihypertensive medication or who have a documented BP off medications <130/80 mmHg at the time of hospital discharge Numerator Patients who are prescribed an oral or transdermal antihypertensive medication or who have a documented BP off medications <130/80 mmHg at the time of hospital discharge Denominator Included patients: All patients with ICH Excluded patients: <18 y of age Length of stay >120 d Comfort measures only documented Enrolled in a clinical trial that would affect the use of antihypertensive medications or a specific BP target Documentation of reason for no long-term antihypertensive medication prescribed at discharge Period of Assessment Hospital discharge Sources of Data Prospective flowsheet, retrospective medical record review, electronic medical record, pharmacy records Rationale Hypertension is the single most important modifiable risk factor for recurrent stroke among patients who survive ICH. Long-term BP control reduces the risk of recurrent ICH. Randomized clinical trials have found early lowering of BP to be safe after spontaneous ICH. Source for Recommendations From the 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 1. BP should be controlled in all patients with ICH (Class I, Level of Evidence A). 2. Measures to control BP should begin immediately after ICH onset (Class I, Level of Evidence A). Method of Reporting Per patient: documentation of an oral or transdermal antihypertensive medication prescribed at the time of hospital discharge or a documented BP of <130/80 mmHg at the time of hospital discharge Per patient population: percentage of patients prescribed an oral or transdermal antihypertensive medication at the time of hospital discharge or a documented BP of <130/80 mmHg at the time of hospital discharge Challenges to Implementation Prescription of an antihypertensive agent at hospital discharge does not guarantee long-term BP control. Documentation is required because an antihypertensive medication is not prescribed at hospital discharge if the BP at that time is 130/80 mmHg. Analogous Measures Endorsed by Other Organizations None AHA indicates American Heart Association; ASA, American Stroke Association; BP, blood pressure; and ICH, intracerebral hemorrhage. Hemphill et al Performance Measures for ICH e257 Appendix. Continued 8. Assessed for Rehabilitation: Percentage of patients with ICH assessed for, or who received, rehabilitation services Numerator Patients who were assessed for, or who received, rehabilitation services during the hospital stay* Denominator Included patients: All patients with ICH Excluded patients: <18 y of age Length of stay >120 d Comfort measures only documented Enrolled in a clinical trial that would affect the use of rehabilitation services Discharged to another acute care hospital Left against medical advice Died Discharged to home or another healthcare facility for hospice care Period of Assessment Acute hospital stay Sources of Data Prospective flowsheet, retrospective medical record review, electronic medical record Rationale ICH often results in severe long-term disability. Comprehensive stroke units that include rehabilitation services demonstrate improved outcomes compared with other models of stroke unit care, and most studies of rehabilitation in stroke have included patients with ICH and ischemic stroke. Source for Recommendations From the 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 1. It is recommended that all patients with ICH have access to multidisciplinary rehabilitation (Class I; Level of Evidence A). From the 2016 AHA/ASA Guidelines for Adult Stroke Recovery and Rehabilitation It is recommended that early rehabilitation for hospitalized stroke patients be provided in environments with organized, interprofessional stroke care (Class I; Level of Evidence A). It is recommended that stroke survivors receive rehabilitation at an intensity commensurate with anticipated benefit and tolerance (Class I; Level of Evidence B). Method of Reporting Per patient: documentation of whether the patient was assessed for, or received, rehabilitation services during the hospital stay Per patient population: percentage of patients who were assessed for, or received, rehabilitation services during the hospital stay Challenges to Implementation Compliance to the measure is already quite high. The association between assessment and initiation of an appropriate rehabilitation plan is unmeasured, leaving uncertainty about the impact of the measure on improved outcomes. Documentation may be challenging to identify if rehabilitation services are delayed on the basis of anticipated institution of care limitations (eg, DNR, hospice, comfort measures only) or acute care hospital transfer. Analogous Measures Endorsed by Other Organizations Identical measures endorsed or used by NQF (Nos. 0244 and 0441), TJC (STK-10), AHA Ischemic Stroke Performance Measure 9, AHA GWTG-Stroke, and CDC PCNASP AHA indicates American Heart Association; ASA, American Stroke Association; CDC, Centers for Disease Control and Prevention; CSTK, Comprehensive Stroke; DNR, do not resuscitate; GWTG Stroke, Get With The Guidelines Stroke; ICH, intracerebral hemorrhage; NQF, National Quality Forum; PCNASP, Paul Coverdell National Acute Stroke program; and TJC, The Joint Commission. *The assessment should be documented in the medical record by a physician, a physical therapist, an occupational therapist, or a speech-language pathologist, as appropriate. If rehabilitation is not needed, then that should be documented explicitly in the record. Appendix. Continued 9. Avoidance of Corticosteroid Use for Elevated Intracranial Pressure: Percentage of patients with ICH who do not receive corticosteroids during acute hospitalization Numerator Patients who do not receive intravenous or oral corticosteroids Denominator Included patients: All patients with ICH Excluded patients: <18 y of age Length of stay >120 d Received corticosteroids before arrival at hospital and being assessed Participation in a clinical trial in which corticosteroids are part of the investigational regimen Documentation of a neurological or other medical condition for which corticosteroids may be indicated, including brain tumor, cerebral venous sinus thrombosis, vasculitis, asthma, COPD, cortisol deficiency, postcraniotomy Period of Assessment From ED arrival until acute care hospital discharge Sources of Data Prospective flowsheet, retrospective medical record review, electronic medical record, pharmacy records Rationale Corticosteroids may be used for the treatment of cerebral mass effect and elevated intracranial pressure if vasogenic edema is present from brain tumors or cerebral abscess. A prior randomized clinical trial in ICH found increased complications and no outcome benefit. This has also been found in traumatic brain and spinal cord injury, and corticosteroids are not recommended in these conditions. Source for Recommendation From the 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 1. Corticosteroids should not be administered for the treatment of elevated intracranial pressure in ICH (Class III; Level of Evidence B). Method of Reporting Per patient: documentation that corticosteroids were given to treat presumed or known elevated intracranial pressure Per patient population: percentage of patients who did not receive corticosteroids for presumed or known elevated intracranial pressure Challenges to Implementation Determining indication for corticosteroid administration 0% Administration of corticosteroids is the desired result. Analogous Measures Endorsed by Other Organizations None AHA indicates American Heart Association; ASA, American Stroke Association; COPD, chronic obstructive pulmonary disease; ED, emergency department; and ICH, intracerebral hemorrhage. Hemphill et al Performance Measures for ICH e259 Disclosures Writing Group Disclosures Writing Group Member Employment Research Grant Other Research Support Speakers Bureau/ Honoraria Expert Witness Ownership Interest Consultant/Advisory Board Other J. Claude Hemphill III University of California, San Francisco None None None None None None None Opeolu M. Adeoye University of Cincinnati None None None None Sense Diagnostics, LLC None None David N. Alexander University of California, Los Angeles None None None None None None None Anne W. Alexandrov University of Tennessee Health Science Center Memphis, College of Nursing and College of Medicine None None None None None None None Sepideh Amin- Hanjani University of Illinois at Chicago None None None None None None None Mary Cushman University of Vermont None None None None None None None Mary G. George CDC DHDSP Atlanta None None None None None None None Peter D. LeRoux MLHC Brain and Spine Center at Lankenau Medical Center None None Integra* None None Codman (unpaid)*; Depuy*; Integra* None Stephan A. Mayer Henry Ford Health System None None None None None Pfizer* None Adnan I. Qureshi University of Minnesota None None None None None None None Jeffrey L. Saver Geffen School of Medicine, UCLA None None None None None None None Lee H. Schwamm Harvard Medical School and Massachusetts General Hospital None None None None None Yale-CORE outcome measure development for CMS* None Kevin N. Sheth Yale University School of Medicine None None None None None None None David Tirschwell University of Washington Harborview Medical Center NIH (ICH secondary prevention grant pending, co-investigator)* None None None None None None This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be significant if (a) the person receives $10000 or more during any 12-month period, or 5% or more of the person s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10000 or more of the fair market value of the entity. A relationship is considered to be modest if it is less than significant under the preceding definition. *Modest. Significant. Reviewer Disclosures Reviewer Employment Research Grant Other Research Support Speakers Bureau/ Honoraria Expert Witness Ownership Interest Consultant/ Advisory Board Other Paul A. Nyquist Johns Hopkins School of Medicine None None None None None None None Magdy H. Selim Beth Israel Deaconess Medical Center/Harvard Medical School NINDS ; AHA* None None None None None None This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be significant if (a) the person receives $10000 or more during any 12-month period, or 5% or more of the person s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10000 or more of the fair market value of the entity. 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