Additional requirements, expanded review process for PSCs

Starting July 1, 2022, The Joint Commission will add requirements and expand to a two-day review process for Primary Stroke Centers (PSCs) that provide mechanical thrombectomy (MT) treatment and are seeking advanced certification or recertification.

MT is a critical component provided by some PSCs to treat ischemic stroke. The additional tracer time and requirements will allow for a thorough review of those services to determine the program’s ability to meet the new requirements. In addition, PSCs that perform MT will be required to submit additional performance measures related to the provision of MTs. The certification application for PSCs also will be revised to capture information regarding MT, including the volume of MTs performed by those organizations that perform the procedure.

If an organization does not indicate that it provides MT on the certification application and it is discovered during the review that the organization does perform this procedure, the review will be rescheduled, and the organization will be responsible for the postponement fee and any additional charges that may be incurred.

View the prepublication standards.

Measures for performing MT (Data collection effective July 1, 2022)

PSC with MT

• All 8 STK measures
• STK-OP-1 Door to Transfer to Another Hospital
• CSTK-01 National Institutes of Health Stroke Scale (NIHSS) Score Performed for Ischemic Stroke Patients
• CSTK-02 Modified Rankin Score (mRS) at 90 Days (process measure)
• CSTK-05 Hemorrhagic Transformation (Overall Rate)
  • CSTK-05a IV Alteplase Only
  • CSTK-05b IA Alteplase or MER
• CSTK-08 Thrombolysis in Cerebral Infarction (TICI) Post-Treatment Reperfusion Grade
• CSTK-09 Arrival Time to Skin Puncture (Overall Rate)
  • CSTK-09a Transfer from Another Hospital
  • CSTK-09b Direct Arrivals
• STK-VOL-1 Eligible Ischemic Stroke Patients Who Receive Mechanical Endovascular Reperfusion Therapy

PSC without MT

• All 8 STK measures
• STK-OP-1 Door to Transfer to Another Hospital
• CSTK-01 National Institutes of Health Stroke Scale (NIHSS) Score Performed for Ischemic Stroke Patients
• STK-VOL-1 Eligible Ischemic Stroke Patients Who Receive Mechanical Endovascular Reperfusion Therapy (i.e., zero attestation needed)*

*No data submission required when the "zero attestation box" is checked in CMIP.