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 Time
Collected For: CSTK-07
Definition:The time (military time) for which 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:What was the time of initiation for IA thrombolytic therapy?

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 IA Thrombolytic Initiation 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 IA Thrombolytic Initiation Date.
Example:
Midnight or 24:00 on 11-24-20xx = 0000 on 11-25-20xx
Notes for Abstraction:
  • Use the time at which initiation of the IA thrombolytic was first documented. If a discrepancy exists in time documentation from different sources, choose the earliest time. If there are two or more different IA thrombolytic initiation times (either different IA thrombolytic episodes or corresponding with the same episode), enter the earliest time.
  • For times that include “seconds”, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00
  • IA thrombolytic initiation time refers to the start time of the thrombolytic bolus/infusion.
  • If the time of IA thrombolytic initiation 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 IA thrombolytic initiation time was 3300. No other documentation in the medical record provides a valid time. Since the IA thrombolytic initiation 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 IA Thrombolytic Initiation Time allows the case to be accepted into the warehouse.
Suggested Data Sources:

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

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

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