Performance Measurement Network

Question: Documentation Compliance for IV t-PA

Currently, we disagee as to why IV t-PA is contraindicated for certain IV t-PA candidates. Physicians are not documenting "thrombolytic considered". We would like to know if this wording is required. If so, how long of a time period do we have to ensure this documentation is placed on the chart.

Answer:

Ischemic stroke patients that arrive at your hospital ED within 2 hrs. of Time Last Known Well should be administered IV t-PA within 3 hrs. of Time Last Known Well, unless MD/APN/PA documents a reason for not administering IV t-PA in the medical record. (See data element definition, IV Thrombolytic Therapy Administered, Section 5, page 47 of the implementation guide.)

http://www.jointcommission.org/CertificationPrograms/PrimaryStrokeCenters/stroke_pm_edition_2_ver_2a.htm

Reasons making the administration of IV t-PA inadvisable, inappropriate and/or undesireable must be linked to t-PA, e.g., "BP 210/100 - No t-PA", in order to select the "NC" path and exclude the case from the measure population. Stroke patients arriving later than 2 hrs. from Time Last Known Well are not in the measure population per the denominator statement.

There is no requirement that the physician document "IV t-PA considered". In January 2008, STK-4 was revised and renamed *IV Thrombolytic Therapy Administered*. There are three allowable values for the data element IV Thrombolytic Therapy Administered: "Yes", "No", and "NC - No, a documented reason exists for not administering t-PA".

Since IV t-PA administration is an acute intervention and the first decision to be made when the patient arrives at your hospital, documentation of IV t-PA administration or reasons for not administering it is expected to be found in the ED record, medication records, progress notes, or transfer forms. Although the timeframe for documentation is not explicitly stated in the definition, the above data sources (ED record, transfer form) imply that documentation should be present shortly after the patient's arrival. Data sources, such as the discharge summary, are not acceptable for this measure, and therefore not listed as suggested data sources.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical, Related Manual - Data Quality Manual
Related documents: STK, STK-04, STK-04 Thrombolytic Therapy Documentation
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