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

Data Element Name: Positive Brain Image
Collected For: CSTK-05
Definition:Documentation of a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage following IV or IA thrombolytic (t-PA) therapy, OR mechanical endovascular reperfusion therapy initiation. The major risk of reperfusion therapy is hemorrhage
Suggested Data Collection Question:Was there a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage following IV or IA thrombolytic (t-PA) therapy, or mechanical endovascular reperfusion therapy initiation?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (YES) Parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was detected on brain imaging following IV or IA thrombolytic (t-PA) therapy, or mechanical endovascular reperfusion therapy initiation.

N (No) Parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was not detected on brain imaging following IV or IA thrombolytic (t-PA) therapy, or mechanical endovascular reperfusion therapy initiation, OR Unable to determine (UTD) from the medical record documentation.
Notes for Abstraction:

  • For purposes of this data element, do not use brain imaging reports for CT/MRI performed prior to IV or IA thombolytic (t-PA) initiation, or mechanical endovascular reperfusion (MER) therapy. Abstract only brain imaging reports for tests done after these interventions to select ‘YES’.
  • Patients with a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage on brain imaging following IV or IA thrombolytic (t-PA) therapy, or mechanical endovascular reperfusion therapy initiation, are acceptable to select “Yes”.
    • A confirmed report is not necessary. Reports of preliminary findings within this timeframe may be used in abstraction.
    • If the report documents that “hemorrhage cannot be excluded”, “cannot R/O hemorrhage”, or “findings suggestive of hemorrhage”, select “Yes”.
  • When conflicting information is documented in the medical record, select ‘YES’.
  • Documentation that the hemorrhage is "old", select 'NO'. Do not infer that a hemorrhage is old unless explicitly documented.
  • See the inclusion list for acceptable examples of documentation of a positive finding. The list is not all inclusive.

Suggested Data Sources:

ONLY acceptable data source:
  • Brain imaging reports
  • Diagnostic test reports
  • Radiology reports
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion

  • Bleed
  • Brain hemorrhage
  • Cerebral hemorrhage
  • ECASS criteria PH1 or PH2
  • Hemorrhage
  • Hemorrhagic conversion
  • Hemorrhagic expansion
  • Hemorrhagic transformation
  • Intracerebral hemorrhage (ICH)
  • Intraventricular hemorrhage
  • Parenchymal hematoma
  • Parenchymal hemorrhage
  • Parenchymal intracerebral hemorrhage
  • Subarachnoid hemorrhage (SAH)

  • ECASS criteria H1 or H2
  • Incidental
  • Micro
  • Petechial
  • Trace

Positive Brain Image
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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