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Question: Last Known Well Y/N?

Patient presented to ER with Last Known Well 2 hours prior to arrival.Patient returned to baseline in the ED. TPA was not given. Patient was then admitted to the hospital. Patient developed a recurrence of stroke symptoms after hospital admission and TPA administered.

1. Would I select YES for Last Known Well since there is clear documentation of LKW prior to arrival and thus use that pre-arrival LKW?

2. If I select Yes to Last Known Well and enter the pre-arrival time, then how would I answer the IV Thrombolytic Therapy Initiation question? Would I select NO since the thrombolytic time given has no relation to the pre-arrival Last Known Well? Thanks.

Answer:

Abstract "YES" for Last Known Well and "YES" for IV Thrombolytic Initiation. If tPA was administered within 3 to 4.5 hours after Time Last Known Well, then select "YES" for Reason for Extending the Initiation of IV Thrombolytic. If initiation was later than 4.5 hours from Time Last Known Well, the case will not be excluded.

IV thrombolytic therapy within 3 hours of time last known well is recommended (Jauch, EC, et. al. 2013). The STK-4 measure captures ischemic stroke patients who receive IV tPA within this timeframe. The measure rate is based on a mathematical calculation. The starting point is Date/Time Last Known Well and the end point Arrival Date/Time at the hospital ED. Please see Timing I box in the algorithm: Arrival Date and Arrival Time minus Date Last Known Well and Time Last Known Well. Patients who arrive to the ED greater greater than 2 hours from time last known well are excluded from the measure. Patients who have a documented Reason for Not Initiating IV Thrombolytic and those with a Reason for Extending IV Thrombolytic Therapy (i.e., 3 to 4.5 hr timeframe per guideline recommendations) are excluded. IV Thrombolytic therapy is not recommended for patients after 4.5 hours from time last known well.

Last year, the inclusion and exclusion guidelines for alteplase were updated (Demaerschalk BM, 2016). Mild strokes are no longer considered a contraindication to thrombolytic therapy. *For patients with mild but disabling stroke symptoms, intravenous alteplase is indicated within 3 hours from symptom onset of ischemic stroke. There should be no exclusion for patients with mild but nonetheless disabling stroke symptoms in the opinion of the treating physician from treatment with intravenous alteplase because there is proven clinical benefit for those patients (Class I; Level of Evidence A). *Within 3 hours from symptom onset, treatment of patients with milder ischemic stroke symptoms that are judged as nondisabling may be considered. Treatment risks should be weighed against possible benefits; however, more study is needed to further define the risk-to-benefit ratio (Class IIb; Level of Evidence C).

In the case of a patient where stroke is not treated initially and later treated outside the timeframe established for the measure, the case will fall out. The measure is unable to differentiate appropriate from inappropriate treatment outside of the specified timeframe for the measure.

Hope this clarifies for you. Thank you.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-4, Last Known Well
Manual: Current Manual (current data collection period; prior to data transmission)
File:

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