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Question: Version 4.4 - Time Last Known Well and Reason Extending IV Thrombolytic

For 2015 discharges, a chart has what I would consider a "Code Stroke" form on it ("Stroke: Acute Evaluation ED and Stroke Alert". There is a space for "Time of Symptom Onset" with " ~1425" written in. There is no documentation of "Time Last Known Well."

The ED dictation states "about 10 minutes prior to admission to the ED, which would have been around 1420 to 1425 hours…."; the H&P dictation states "presents to the ED 30 minutes after starting to have slurring of speech (with time of arrival being 1437..."; neuro consult states "she suddenly felt like she was having a stroke around 2:40 p.m. … presented to the hospital at 1427 with slurred speech and swallowing difficulties..."; and the ED nursing notes states "difficulty talking and swallowing started 10 min ago."

Based on the new notes for abstraction is it correct to abstract 14:07 since all of this documentation is onset of symptoms and the earliest is the H&P dictation of a presentation to the ED after 30 minutes of symptoms?

Next, Upon reading further, there is a consult by the neurologist who saw the patient in the ED and dictates “saw the patient at 1510 at which time she had a left-sided facial droop as well as some dysarthria and difficulty swallowing… 1630 she started to improve sounding less slurred in her speech and facial droop was resolving. At that time her stroke scale was a total of 3 but then continued to improve to some minor paralysis so improved to a stroke scale total of 2. The decision not to offer t-PA was made based on exclusion criteria that if her stroke is resolving and t-PA is a relative contraindication at that point. However, at 1800 I was notified that the patient had difficulty moving her left thumb and so I returned to re-examine the patient and based on symptoms that were progressing, I offered t-PA as a treatment at that time based on presenting with onset of symptoms within the time window at that time. At that time the patient’s stroke scale progressed to a total of 4…..”

Would this dictation change my time of onset of symptoms or last known well? The symptoms were “resolving” but not “resolved” but recurred AFTER arrival while in the ED. Can I consider the time of 1800 the “most recent” episode and use it for my time instead of the 1407? There is a rule in the last known well section stating for “symptoms that occurred at a date or time following hospital arrival, select “no.” But the symptoms originally started before arrival just got better and then worsened while in the ED…..prompting administration of the t-PA.

This case is falling out but the physician clearly documents why there was a delay and why he decided to give the t-PA after all. It doesn’t seem like it should fall out but the time of onset is 1407 and the t-PA was given at 1855 so it is outside the 3-4.5 hours.

Is it correct to answer Yes to Last Known Well and enter the LKW time as 14:07 based on this documentation?



It seems that the problem is lack of clear documentation of Time Last Known Well which was the driver for revising the STK-4 data elements since time last known well and time of symptom onset may of may not be the same time depending on what is documented in the patient's medical record. The Code Stroke Form was made the preferred data source because it should have a designated field specifically for "Time Last Known Well".

Per Version 4.4 definition for "Time Lsst Known Well", use physician documentation first before nursing and then the earliest documented time when multiple times are documented. The "Stroke: Acute Evaluation ED and Stroke Alert" form does not have a designated field for "Time Last Known Well" and only documents time of symptom onset. Since time last known well and time of symptom onset are not considered synonymous, use the abstraction guidelines for multiple times. The earliest time based on MD documentation seems to be 30 minutes prior to arrival time.

Notes for abstraction for "Time Last Known Well" state: • If there are multiple times of last known well documented in the absence of the Time Last Known Well explicitly documented on a “Code Stroke” form, use physician documentation first before other sources, e.g., nursing, EMS. Example: “Patient last seen normal this morning at 1000” per H&P. ED nurse documented 09:50 as time last well. Time Last Known Well is 1000. • If multiple times last known well are documented by different physicians or by the same provider, use the earliest time documented.

For "Reason for Extending the Initiation of IV Thrombolytic" would consider neuro documentation i.e., "The decision not to offer t-PA was made based on exclusion criteria that if her stroke is resolving and t-PA is a relative contraindication at that point" as an "other" reason documened by MD/APN/PA and select 'YES'. This note provides a medical reason linked with t-PA.

STK-4 is constructed for patients who arrive to your hospital ED within 2 hours of time last known well. If Time Last Known Well is after Arrival Time the case will be rejected by the CMS and TJC data warehouse because Timing 1 calculation (see STK-4 algorithm would equal less than zero minutes. Therefore, the Time Last Known Well that you enter must always be before hospital arrival to include the case. 1800 won't work for TLKW because it is after the arrival time and in this case you have a TLKW to use prior to arrival, so that is the time to use.

Hope this clarifies for you.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-04, Last Known Well,
Manual: Future Manual (data collection period has not yet started)

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