Specifications Manual for Joint Commission National Quality Measures (v2017B2)
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Release Notes:
Data Element
Version 2017B2

Data Element Name: Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time
Collected For: CSTK-11, CSTK-12,
Definition:The time (military time) that a Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade of 2B/3 was first documented during the mechanical thrombectomy procedure.
Suggested Data Collection Question:What was the time that a TICI 2B/3 was first documented during the mechanical thrombectomy procedure?
Format:
Length:5 - HH-MM (with or without colon) or UTD
Type:Time
Occurs:1
Allowable Values:


HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine

Time must be recorded in military time format. With the exception of Midnight and Noon:
  • If the time is in the a.m., conversion is not required
  • If the time is in the p.m., add 12 to the clock time hour

Examples:

Midnight = 00:00
Noon = 12:00
5:31 am = 05:31
5:31 pm = 17:31
11:59 am = 11:59
11:59 pm = 23:59

Note:
00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.

When converting Midnight or 24:00 to 00:00, do not forget to change the Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Date.
Example:
Midnight or 24:00 on 11-24-20xx = 0000 on 11-25-20xx
Notes for Abstraction:
  • Use the time a TICI 2B/3 was first documented. If a discrepancy exists in time documentation from different sources, choose the earliest time. If multiple times are documented during the procedure, use the earliest time.
  • The procedure end time may be used if an earlier time is not documented during the procedure.
  • For times that include “seconds”, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00.
  • If the time a TICI 2B/3 was first documented is unable to be determined from medical record documentation, select “UTD”.
  • The medical record must be abstracted as documented (taken at “face value”). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select “UTD”.
    Example:
    Documentation indicates the Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time was 3300. No other documentation in the medical record provides a valid time. Since the Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.
    Note:
    Transmission of a case with an invalid time as described above will be rejected from the Joint Commission’s Data Warehouse. Use of “UTD” for Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time allows the case to be accepted into the warehouse.
Suggested Data Sources:

  • Consultation notes
  • Progress notes
  • Operative notes
  • Procedure notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time
Specifications Manual for Joint Commission National Quality Measures (v2017B2)
Discharges 01-01-18 (1Q18) through 06-30-18 (2Q18)
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