Performance Measurement Network

Question: Earliest principal procedure time/first pass time

Our hospital uses an angiography datasheet to document procedure times. I am uncertain what to select for both the "earliest principal/other reperfusion procedure time," as well as what to select for the "first pass" time. They list out the following:

Patient in room: 1235 Patient on table: 1239 IA puncture: 1244 First run in target vessel: 1246 Catheter in brain: 1258

1. What would I select for the earliest procedure start time? 2. What would I select for the IA t-PA or MER initiation time? 3. What would I select for the first pass time? (I am told by our stroke coordinator that the catheter in brain would be considered the first pass

Thank you!


Procedure Start Time: The procedure record, i.e. angiography sheet, is the priority data source. The inclusion terms i.e. "procedure start" procedure begin" and "procedure initiated" are not documented on the angio sheet. Therefore, you need to look for these inclusion terms documented in other sources first, e.g., anesthesia record, progress notes, procedure notes, etc. (see Suggested Data Sources for these data elementsbefore selecting a time. If these inclusion terms cannot be found in sources other than the angio record, then go to other terms and select the earliest time. In the example provided, the earliest time would be "in room 1235".

IA t-PA or MER Initiation Time: In the example provided, IA puncture time is the groin puncture time which is the wrong time to use. Do not use groin puncture or procedure start time for this data element. A start time for IA infusion is not documented in the example provided. If a start time/IA infusion initiation time is not documented elsewhere in the medical record, then the patient must not have received IA thrombolytic which leaves only a MER procedure (one time - use the MER time).

First Pass Time: The inclusion terms currently specified for First Pass of a Mechanical Reperfusion Device are "deployment" and "pass". CSCs have provided feedback regarding possible alternative terms for pass and deployment via this Q&A forum. "Run" has been proposed as an alternative term. First run in target vessel is closer to the data element definition than catheter in brain. This would also be your MER Time for IA t-PA or MER Initiation in the event that the case exampled does not have documented IA infusion initiation/start time in the record.

Hope this clarifies for you.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: CSTK, CSTK - Earliest Principal Procedure Time/First Pass Time,
Manual: Current Manual (current data collection period; prior to data transmission)

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