Specifications Manual for Joint Commission National Quality Measures (v2018A)
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Release Notes:
Data Element
Version 2018A

Data Element Name: First Pass Time
Collected For: CSTK-07
Definition:The time (military time) of the first pass (i.e., mechanical deployment) of a clot retrieval device at this hospital.
Suggested Data Collection Question:What is the time of the first pass (i.e., mechaical deployment) of a clot retrieval device at this hospital?

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 First Radiographic Image 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 First Radiographic Image Date.
Example:
Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx
Notes for Abstraction:
  • 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 First Pass Time 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 first pass time was 3300. No other documentation in the medical record provides a valid time. Since the first pass 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 First Pass Time allows the case to be accepted into the warehouse.
  • The earliest time should be used regardless of how many vessels were treated or which ones were successful vs. unsuccessful.
Suggested Data Sources:

  • Consultation notes
  • Diagnostic test reports
  • Procedure notes

* Operative notes
  • Procedure report
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None
  • Anesthesia start time
  • Groin puncture time
  • Procedure start time

First Pass Time
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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