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

Data Element Name: IA Thrombolytic Initiation
Collected For: CSTK-07
Definition:Intra-arterial (IA) thrombolytic therapy was initiated at this hospital. IA thrombolytics convert plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving thrombus.
Suggested Data Collection Question:Is there documentation that IA thrombolytic therapy was initiated at this hospital?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes) IA thrombolytic was initiated at this hospital.

N (No) IA thrombolytic was not initiated at this hospital, OR unable to determine from medical record documentation.
Notes for Abstraction:
  • When a “start time” or “infusion time” for IA thrombolytic is documented in the medical record, select “Yes”.
  • If the data element "IA Route of t-PA Administration" is "Yes", select "Yes" for this data element.
  • If IA thrombolytic initiation is unable to be determined from medical record documentation, select “No”.
  • If IA thrombolytic was administered at another hospital and the patient subsequently transferred to this hospital, select “No”.
Suggested Data Sources:

  • Consultation notes
  • Diagnostic test reports
  • Operative notes
  • Procedure notes

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Only Acceptable Thrombolytic Therapy for Stroke:
  • Activase
  • Alteplase
  • IA t-PA
  • Recombinant Tissue Plasminogen Activator (rt-PA)
  • Intravenous (IV) t-PA
  • IA administration of thrombolytic agents not listed as inclusions

IA 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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