CDE Detailed Report

Disease: Stroke
Sub-Domain: History of Disease/Injury Event
CRF: Hospital Arrival

Displaying 1 - 14 of 14
CDE ID CDE Name Variable Name Definition Short Description Additional Notes (Question Text) Permissible Values Description Data Type Disease Specific Instructions Disease Specific Reference Population Classification (e.g., Core) Version Number Version Date CRF Name (CRF Module / Guideline) Sub Domain Name Domain Name Size Input Restrictions Min Value Max Value Measurement Type External Id Loinc External Id Snomed External Id caDSR External Id CDISC
C05404 Symptom onset date and time SymptmOnsetDateTime Date (and time, if applicable and known) reported for onset of participant's/subject's symptoms Date (and time, if applicable and known) reported for onset of participant's/subject's symptoms Date and Time of discovery of stroke symptoms Date or Date & Time

The time of symptom discovery is either the time at which the patient was first noted by another person to have stroke symptoms or the self-reported time by an individual who may not be accurate or reliable in their assessment of stroke symptoms onset (e.g., in the setting of neglect or anosagnosia, or aphasia). When the event is witnessed by another person, then the time of discovery is identical to the time of last known well; however, when unwitnessed or self-reported by an unreliable patient, this time of discovery will be later chronologically than the time last known well. Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

American Heart/American Stroke Association. (2018). Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (© 2018, American Heart/American Stroke Association). Available at: https://www.heart.org/-/media/files/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke/stroke-fact-sheet_-final_ucm_501842.pdf?la=en; Paul Coverdell National Acute Stroke Registry Adult;Pediatric Supplemental 3.00 2013-07-25 08:54:08.2 Hospital Arrival/Admission History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

C14199 Stroke complication of medical/ surgical procedure or therapy likelihood type StrokCompMedSurProcTherLikeTyp Was stroke a complication of medical or surgical procedure or therapy? This element attempts to capture if the stroke event was related to a medical or surgical procedure/ therapy the patient recently received (e.g., multifocal emboli after cardiac bypass surgery). Likelihood that stroke was a complication of medical or surgical procedure or therapy the patient recently received (e.g., multifocal emboli after cardiac bypass surgery). Was stroke a complication of a recent medical or surgical procedure or therapy (i.e. less than 30 days) Definitely;Probably;Possibly;Unlikely;Not applicable clear causal link such as multifocal emboli after cardiac bypass surgery;high likelihood of causality but other etiologies could also be plausible explanations;causality unclear but proximity to the procedure makes this a consideration;the causal link is not well established and the stroke has another more likely etiology;Not applicable Alphanumeric

Choose one

No references available Adult;Pediatric Exploratory 3.00 2013-06-21 00:00:00.0 Hospital Arrival/Admission History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C05408 Hospital admission date and time HospitlAdmissDateTime Date (and time, if applicable and known) the participant/subject was admitted to the hospital Date (and time, if applicable and known) the participant/subject was admitted to the hospital Date of admission to your hospital Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).
Supplemental - Highly Recommended based on study type, disease stage and disease type.

American Heart/American Stroke Association. (2018). Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (© 2018, American Heart/American Stroke Association). Available at: https://www.heart.org/-/media/files/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke/stroke-fact-sheet_-final_ucm_501842.pdf?la=en; Paul Coverdell National Acute Stroke Registry Adult;Pediatric Supplemental?Highly Recommended 3.00 2013-07-25 08:54:08.2 Hospital Arrival/Admission History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

C14625 Hospital arrival date and time HospArrivDateTime Date (and time, if applicable and known) the participant/subject arrived at the hospital Date (and time, if applicable and known) the participant/subject arrived at the hospital Date of hospital arrival Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

Supplemental - Highly Recommended based on study type, disease stage and disease type

American Heart/American Stroke Association. (2018). Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (© 2018, American Heart/American Stroke Association). Available at: https://www.heart.org/-/media/files/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke/stroke-fact-sheet_-final_ucm_501842.pdf?la=en; Paul Coverdell National Acute Stroke Registry Adult;Pediatric Supplemental?Highly Recommended 3.00 2013-06-21 00:00:00.0 Hospital Arrival/Admission History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

C05418 Hospital transport type HospTrnsprtTyp Type of transportation from injury scene to hospital Type of transportation from injury scene to hospital Type of transport to hospital Mobile Stroke Unit;EMS from home/scene;Private transportation/taxi/other from home/scene;Unknown;Other, specify Mobile Stroke Unit;EMS from home/scene;Private transportation/taxi/other from home/scene;Unknown;Other, specify Alphanumeric

This refers to the method of transport to your hospital, not to the method of initial transport to another facility if the patient was subsequently transferred to your hospital.

American Heart/American Stroke Association. (2018). Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (© 2018, American Heart/American Stroke Association). Available at: https://www.heart.org/-/media/files/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke/stroke-fact-sheet_-final_ucm_501842.pdf?la=en; Paul Coverdell National Acute Stroke Registry Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Hospital Arrival/Admission History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C18686 Hospital transport other text HospTrnsprtOTH The free-text field related to 'Hospital transport type' specifying other text. Type of transportation from injury scene to hospital The free-text field related to 'Hospital transport type' specifying other text. Type of transportation from injury scene to hospital Other, specify Alphanumeric

This refers to the method of transport to your hospital, not to the method of initial transport to another facility if the patient was subsequently transferred to your hospital.

American Heart/American Stroke Association. (2018). Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (© 2018, American Heart/American Stroke Association). Available at: https://www.heart.org/-/media/files/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke/stroke-fact-sheet_-final_ucm_501842.pdf?la=en; Paul Coverdell National Acute Stroke Registry Adult;Pediatric Supplemental 1.00 2014-05-27 13:34:46.0 Hospital Arrival/Admission History of Disease/Injury Event Disease/Injury Related Events 4000

Free-Form Entry

C14190 Stroke symptoms discover location type StrokSymDiscLocTyp Where was the patient when stroke was detected or when symptoms were discovered? Indicate the type of facility or setting from which the patient came from when stroke like symptoms were discovered. Where was the patient when stroke was detected or when symptoms were discovered? Indicate the type of facility or setting from which the patient came from when stroke like symptoms were discovered. Patient location when stroke symptoms discovered Stroke occurred while patient was an inpatient in your hospital;Unknown;Another acute care facility (e.g. outside hospital);Chronic healthcare facility (e.g. skilled nursing facility);Not in a healthcare setting (e.g. at place of residence and not in a hospital or clinic);Outpatient healthcare setting (e.g. clinic) Stroke occurred while patient was an inpatient in your hospital;Unknown;Another acute care facility (e.g. outside hospital);Chronic healthcare facility (e.g. skilled nursing facility);Not in a healthcare setting (e.g. at place of residence and not in a hospital or clinic);Outpatient healthcare setting (e.g. clinic) Alphanumeric

If the patient was a resident of a nursing home, but was out with family for the day and suffered a stroke and the family/EMS brought the patient to your hospital, choose "Not in a healthcare setting". If the patient was at home, at work of even a visitor in your hospital and had stroke symptoms, then choose "Not in a healthcare setting". If the patient was transferred to your hospital from another hospital's ED or inpatient unit but was outside of a healthcare facility when the stroke occurred, choose "Not in a healthcare setting". If the patient was a resident of a nursing home and the stroke occurred at the NH, choose "Chronic healthcare facility". A chronic care facility would include nursing home, long-term care facility, inpatient rehab facility, and assisted-living facility. If the patient is at a clinic or physician office visit, or at your hospital but receiving outpatient procedure or service that did not require the patient to be admitted as an inpatient, select "Outpatient healthcare setting". If the patient was an inpatient in your hospital choose "Stroke occurred while patient was an inpatient at your hospital". If the patient was already within your ED or hospital and experienced new onset of stroke symptoms, then this is considered an inpatient stroke or TIA. Only those hospitals that are interested in collecting information regarding inpatient stroke care should enter these patients. Patients who have transient symptoms that are present on arrival to the ED but resolve, and then later return during the hospitalization and meet criteria for ischemic stroke should all be entered as inpatient strokes.

American Heart/American Stroke Association. (2018). Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (© 2018, American Heart/American Stroke Association). Available at: https://www.heart.org/-/media/files/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke/stroke-fact-sheet_-final_ucm_501842.pdf?la=en; Paul Coverdell National Acute Stroke Registry Adult;Pediatric Supplemental 3.00 2013-06-21 00:00:00.0 Hospital Arrival/Admission History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C14191 Last known to be well date and time LastKnownWellDateTime The date and time at which the patient was last known to be without the signs and symptoms of the current stroke or at his or her prior baseline. This element captures the date and time for last known well that is determined to be the most accurate after all the data have been evaluated and additional witnesses interviewed (if applicable). The date and time at which the patient was last known to be without the signs and symptoms of the current stroke or at his or her prior baseline. Date and Time patient last known to be well (or at pre-stroke baseline) Date or Date & Time

When was the patient last known to be well (i.e., in their usual state of health or at their baseline), prior to the beginning of the current stroke/TIA? (To within 15 minutes of exact time is acceptable). If there are multiple times of "last known well" documented, either because subsequent more accurate information became available or because of different levels of expertise in sorting out the actual time of "last known well", use the time recorded according to the following hierarchy: (1) stroke team/neurology; (2) admitting physician; (3) emergency department physician; (4) ED nursing notes; (5) EMS Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

Supplemental - Highly Recommended based on study type, disease stage and disease type

American Heart/American Stroke Association. (2018). Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (© 2018, American Heart/American Stroke Association). Available at: https://www.heart.org/-/media/files/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke/stroke-fact-sheet_-final_ucm_501842.pdf?la=en; Paul Coverdell National Acute Stroke Registry Adult;Pediatric Supplemental?Highly Recommended 3.00 2013-06-21 00:00:00.0 Hospital Arrival/Admission History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

C14192 Symptom awaken discover indicator SympAwakenDiscInd Indicate if symptoms were discovered shortly upon awakening from sleep. Indicate if symptoms were discovered shortly upon awakening from sleep. Symptom discovery on awakening Yes;No;Unknown Yes;No;Unknown Alphanumeric

Choose one. Unknown should be used if not documented or cannot be determined.

No references available Adult;Pediatric Supplemental 3.00 2013-06-21 00:00:00.0 Hospital Arrival/Admission History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C14194 Hospital not admitted but transferred to another acute care hospital indicator HospNotAdmTrnsfAnthAcCrHospInd Whether a patient presented to the Emergency Department of the study hospital and was transferred to an outside hospital. Was patient evaluated in the ED for acute Stroke or TIA and subsequently transferred to another acute care hospital rather than being admitted to your hospital? Whether a patient presented to the Emergency Department of the study hospital and was transferred to an outside hospital. Was patient evaluated in the Emergency Department (ED) for acute Stroke or TIA and subsequently transferred to another acute care hospital rather than being admitted to your hospital Yes;No;Unknown Yes;No;Unknown Alphanumeric

Choose one. Select Yes for patients who are evaluated in the Emergency Department, found to have a diagnosis of Ischemic Stroke, Subarachnoid Hemorrhage, Intracerebral Hemorrhage or Transient Ischemic Attack, and are subsequently transferred to another acute care hospital rather than being admitted to hospital. Select No for patients who are admitted or are not transferred to another acute hospital. Select Unknown if Not documented or Cannot be determined.

American Heart/American Stroke Association. (2018). Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (© 2018, American Heart/American Stroke Association). Available at: https://www.heart.org/-/media/files/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke/stroke-fact-sheet_-final_ucm_501842.pdf?la=en; Paul Coverdell National Acute Stroke Registry Adult;Pediatric Supplemental 3.00 2013-06-21 00:00:00.0 Hospital Arrival/Admission History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C14195 Hospital point of origin for admission or visit type HospPointOrigAdmVisTyp Documents whether the patient originated from the community or was transferred from one hospital to the study hospital. Documents whether the patient originated from the community or was transferred from one hospital to the study hospital. Point of origin for admission/visit Not in a healthcare facility;Another acute care facility;Chronic healthcare facility;Outpatient healthcare facility;Stroke occurred after hospital arrival (in ED/observation unit/inpatient);Unknown Not in a healthcare facility;Another acute care facility;Chronic healthcare facility;Outpatient healthcare facility;Stroke occurred after hospital arrival (in ED/observation unit/inpatient);Information not Available. The means by which the patient was admitted to this hospital is unknown. Alphanumeric

Choose one response. The answer to this question is independent of the answer for Patient Location When Stroke Symptoms Discovered. This question asks where the patient was located prior to arriving at your hospital, not where the patient was when they first developed stroke symptoms. This element is intended to capture data about patients who are admitted to the hospital because of stroke events and is not for use with inpatient strokes (i.e., inpatient stroke = stroke that occurs while a patient is an inpatient in the hospital).

The Joint Commission (TJC) Adult;Pediatric Supplemental 3.00 2013-06-21 00:00:00.0 Hospital Arrival/Admission History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C14196 Hospital location patient first received care type HospLocPatFirstReceiveCarTyp Area of the hospital the patient first evaluated Area of the hospital the patient first evaluated Location patient first received care at hospital Emergency Department/ Urgent Care;Direct Admit, not through ED;Imaging Suite;Unknown Emergency Department/ Urgent Care;Direct Admit, not through ED;Imaging Suite;Unknown Alphanumeric

Choose one. A patient presenting to the emergency department with stroke symptoms would have first received care in the Emergency Department (ED). However, for patients who are transferred from an outside hospital and directly admitted, then the place of first care would be the service where they were admitted (e.g., neurology inpatient service, intensive care unit). Select imaging for patients with suspected acute stroke who are taken directly to the imaging area prior to the ED registration. This data element is not applicable to strokes that occur after a patient has already been admitted or receiving care in the ED for another condition.

American Heart/American Stroke Association. (2018). Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (© 2018, American Heart/American Stroke Association). Available at: https://www.heart.org/-/media/files/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke/stroke-fact-sheet_-final_ucm_501842.pdf?la=en; Paul Coverdell National Acute Stroke Registry Adult;Pediatric Supplemental 3.00 2013-06-21 00:00:00.0 Hospital Arrival/Admission History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

C14197 Hospital care upon admission type HospCarAdmTyp Where the patient was cared for and by whom (Where was the patient cared for and by what service?) Where the patient was cared for and by whom (Where was the patient cared for and by what service?) Patient care upon admission Stroke Consult;In Stroke Unit;No Stroke Consult;Not in Stroke Unit;Neurology Admission Stroke Consult;In Stroke Unit;No Stroke Consult;Not in Stroke Unit;Neurology Admission Alphanumeric

Choose all that apply. To track the service on which care was rendered upon admission, select from the available options to indicate type of admission, whether a stroke consult was available, and whether this was in a stroke unit or not. First indicate if the patient was admitted by a neurologist or other service. Then indicate if the patient had a stroke consult. Finally indicate if the patient was cared for in a stroke unit.

American Heart/American Stroke Association. (2018). Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (© 2018, American Heart/American Stroke Association). Available at: https://www.heart.org/-/media/files/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke/stroke-fact-sheet_-final_ucm_501842.pdf?la=en; Paul Coverdell National Acute Stroke Registry Adult;Pediatric Supplemental 3.00 2013-06-21 00:00:00.0 Hospital Arrival/Admission History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected

C14198 Hospital presumptive admission diagnosis type HospPresAdmDiagTyp The presumptive diagnosis tries to identify presumptive diagnosis at the time of hospital admission. The presumptive diagnosis tries to identify presumptive diagnosis at the time of hospital admission. Presumptive diagnosis at time of hospital admission Ischemic Arterial Stroke;Transient ischemic attack;Ischemic Venous Stroke;Subarachnoid hemorrhage;Intracranial Hemorrhage;Intracerebral hemorrhage;Not stroke related diagnosis;Unknown Ischemic Arterial Stroke;Transient ischemic attack;Ischemic Venous Stroke;Subarachnoid hemorrhage;Intracranial Hemorrhage;Intracerebral hemorrhage;Not stroke related diagnosis;Unknown Alphanumeric

Choose one response. This field is useful in understanding why certain therapies were performed or omitted, and to understand the nature of missed or delayed diagnosis

American Heart/American Stroke Association. (2018). Get With The Guidelines (GWTG) Stroke Patient Management Tool Coding Instructions (© 2018, American Heart/American Stroke Association). Available at: https://www.heart.org/-/media/files/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke/stroke-fact-sheet_-final_ucm_501842.pdf?la=en; Paul Coverdell National Acute Stroke Registry Adult;Pediatric Supplemental 3.00 2013-06-21 00:00:00.0 Hospital Arrival/Admission History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

CSV