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

Data Element Name: IA t-PA or MER Initiation Date
Collected For: CSTK-05
Definition:The date associated with the time that IA thrombolytic (t-PA) therapy or mechanical endovascular reperfusion (MER) therpy was initiated to a patient with ischemic stroke at this hospital. IA thrombolytics convert plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving thrombus. Reperfusion therapies also include procedures utilizing mechanical thrombectomy devices with or without pharmacological thrombolysis.
Suggested Data Collection Question:What is the date associated with the time that IA t-PA or MER was initiated at this hospital?
Format:
Length:10 - MM-DD-YYYY (includes dashes) or UTD
Type:Date
Occurs:1
Allowable Values:


MM = Month (01-12)
DD = Day (01-31)
YYYY = Year (2001-Current Year)
UTD = Unable to Determine
Notes for Abstraction:
  • If the date IA t-PA or MER was initiated 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 date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select “UTD”.
    Example:
    Documentation indicates the MER initiation date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the MER initiation date is outside of the range listed in the Allowable Values for “Day,” it is not a valid date and the abstractor should select “UTD”.
    Note: Transmission of a case with an invalid date as described above will be rejected from the Joint Commission''s Data Warehouse. Use of “UTD” for IA t-PA or MER Initiation Date allows the case to be accepted into the warehouse.
Suggested Data Sources:

  • Consultation notes
  • Progress notes
  • Operative notes
  • Diagnostic test reports
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

IA t-PA or MER Initiation Date
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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