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

Data Element Name: Highest NIHSS Score Documented Within 36 Hours Following IV Thrombolytic Initiation
Collected For: CSTK-05
Definition:The highest NIHSS score documented within 36 hours following initiation of IV thrombolytic (t-PA) therapy. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language.
Suggested Data Collection Question:What is the highest NIHSS score documented within 36 hours following initiation of IV (t-PA) thrombolytic therapy?
Format:
Length:3
Type:Alphanumeric
Occurs:1
Allowable Values:


Score = 0-42
UTD = Unable to Determine
Notes for Abstraction:
  • The NIHSS score may be documented by the physician/APN/PA or nurse (RN).
  • Look for the highest NIHSS score documented in less than or equal to 36 hours following initiation of IV thrombolytic (t-PA) therapy.
  • For purposes of this data element, score documentation between 0 and 42 is acceptable.
  • If only one NIHSS score is documented within the first 36 hours following initiation of IV thrombolytic (t-PA) therapy and no other NIHSS score(s) are available for comparison, enter the value for that score.
  • If multiple scores are documented within the first 36 hours following initiation of IV thrombolytic (t-PA) therapy, select the highest score.
    EXAMPLES:
    • NIHSS Score is 10 at 1500 and 20 at 2300. Both scores are documented following the initiation of IV thrombolytic therapy. Select NIHSS score of 20.
    • IV thrombolytic therapy initiated on 9/5/20XX at 0900. NIHSS score is 8 on 9/5/20XX at 2300, 10 on 9/6/20XX at 0100, and 8 on 9/6/20XX at 0300. Select NIHSS score 10.
    • IV thrombolytic therapy initiated on 9/5/20XX at 0900. NIHSS score 3 on 9/6/20XX at 0900, 2 on 9/8/20XX at 0900, and 6 on 9/10/2012 at 0900. Select 3.
  • If no NIHSS score is documented within 36 hours following IV thrombolytic (t-PA) therapy, select “UTD”.
  • If unable to determine the highest score documented within 36 hours following IV thrombolytic (t-PA) therapy, select “UTD”.
Suggested Data Sources:

  • Consultation notes
  • Emergency department record
  • History and physical
  • Nursing flow sheet
  • Progress notes
  • Admitting note
  • Nursing assessment
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None
  • Modified NIHSS scores
  • Estimated NIHSS scores
  • Scoring methodologies other than NIHSS

Highest NIHSS Score Documented Within 36 Hours Following IV Thrombolytic Initiation
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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