IV Thrombolytic Initiation

Specifications Manual for Joint Commission National Quality Measures (v2016A1)

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Release Notes:
Data Element
Version 2016A1

Data Element Name:

IV Thrombolytic Initiation

Collected For:

STK-4,

Definition:

Intravenous (IV) thrombolytic therapy was initiated at this hospital. IV thrombolytics convert plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving thrombus. IV t-PA is the only FDA-approved IV thrombolytic for stroke.

Suggested Data Collection Question:

Is there documentation that IV thrombolytic therapy was initiated at this hospital?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) IV thrombolytic was initiated at this hospital.

N (No) IV thrombolytic was not initiated at this hospital, OR unable to determine from medical record documentation.

Notes for Abstraction:

When a “hang time” or “infusion time” for IV thrombolytic is documented in the medical record, select “Yes.”
If IV thrombolytic therapy was administered at another hospital and patient was subsequently transferred to this hospital, select “No.”
If the patient was transferred to this hospital with IV thrombolytic infusing, select “No.”

Suggested Data Sources:

Emergency department record
Progress notes
IV flow sheets
Medication records

Additional Notes:

Guidelines for Abstraction:

Inclusion

Exclusion

Only Acceptable Thrombolytic Therapy for Stroke:

Activase
Alteplase
IV t-PA
Recombinant t-PA Tissue plasminogen activator

Intra-arterial (IA) t-PA
Thrombolytic administration to flush, open, or maintain patency of a central line, e.g., PICC line

IV Thrombolytic Initiation

Specifications Manual for Joint Commission National Quality Measures (v2016A1)
Discharges 10-01-16 through 12-31-16 (4Q16)