Performance Measurement Network

Question: Last known well when symptoms resolve then reoccur

Patient arrived in the ED w/ acute stroke symptoms that occured prior to arrival. The symptoms completely resolved while they were in the ED, only to reoccur again while still in the ED. The treating neurologist "reset the clock" and IV tPA was given based on the 2nd onset time. From a data collection point of view for STK 4, is my understanding correct that I am to use the first symptom onset time rather than the second onset time for time last known well? (Even in scenarios where the symptoms resolve and reoccur prior to arrival?) Our treating physician's document the onset time using the latest time in these scenarios and will treat based on that time IF the symptoms have completely resolved. Just want to make sure that I should be using the earlier time from a data abstraction standpoint. Thank you.


The STK-4 timimng computation use Time Last Known Well and Arrival Time to determine if a patient is included in the STK-4 denominator population (i.e., "Acute ischemic stroke patients whose time of arrival is within 2 hours (less than or equal to 120 minutes) of time last known well). The TIMING 1 computation is Arrival Date and Arrival Time minus Date Last Known Well and Time Last Known Well >/= zero minutes and </= 120 minutes. If greater than 120 minutes, then the patient is excluded at this point in the algorithm.

Therefore, Time Last Known Well must be prior to arrival time. The algorithm computation cannot be a negative number, i.e. TLKW in ED after hospital arrival.

If the patient's symptoms completely resolve (NIHSS score of zero) by the time of hospital and the patient is within the 2 hr window, then enter the TLKW prior to hospital arrival, select 'NO' for IV Thrombolytic Initiation, and 'Yes' for Reason for Not Initiating IV Thrombolytic (documented NIHSS score of zero on arrival or documenation that t-PA was not given/delayed because of symptom resolution on arrival to hospital). This is the case even if symptoms recur in the ED after hospital arrival and IV t-PA is administered.

If the patient has multiple TIA prior to hospital arrival with complete symptom resolution in between episodes, use the most recent time last known well/most recent episode. e.g., "Patient with headache yesterday that resolved by early evening. Went to church this morning with family, and suddenly unable to speak during the service around 10 AM." Use 10 AM for TLKW.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK, Data/Time Last Known Well

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