Release Notes:
Data Element
Version 2018A
| Data Element Name: |
Delayed Endovascular Rescue Procedure |
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| Collected For: |
CSTK-09, CSTK-11 |
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| Definition: | Endovascular treatment (EVT) with a device and/or intra-arterial (IA) thrombolysis (t-PA) that was first performed at this hospital later than 8 hours after hospital arrival. |
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| Suggested Data Collection Question: | Is there documentation in the medical record that the first endovascular treatment procedure was initiated greater than 8 hours after arrival at this hospital? |
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| Format: |
| Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Y (Yes) There is documentation that the first endovascular treatment procedure was initiated greater than 8 hours after arrival at this hospital.
N (No) There is no documentation that the first endovascular treatment procedure was initiated greater than 8 hours after arrival at this hospital, OR unable to determine from medical record documentation. |
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| Notes for Abstraction: |
- If EVT was initiated greater than 8 hours after hospital arrival AND there was no EVT procedure, i.e., mechanical embolectomy/ thrombectomy and/or IA thrombolysis (t-PA) performed during the first 8 hours after hospital arrival, then select "Yes".
Example: Patient arrives at the hospital ED on 01-11-20XX at 0013. NIHSS 2. IV t-PA given. On 01-11-20XX, patient found with slurred speech, left-sided facial droop and paresthesia. Stroke alert call at 0900. Thrombectomy performed on 01-11-20XX at 1010.
- If EVT was initiated within 8 hours after hospital arrival and another EVT procedure performed later than 8 hours following hospital arrival, select "No".
Example: Patient arrives at the hospital ED on 01-15-20XX at 1513. IA t-PA initiated at 1605. Thrombectomy performed 01-17-20XX at 0640.
- If unable to determine, select "No".
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| Suggested Data Sources: |
- Consultation notes
- Diagnostic test reports
- Operative notes
- Operative report
- Procedure notes
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion |
Exclusion |
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Patients with ICD-10-PCS procedure codes on Table 8.1a Thrombolytic Agent Procedures or Table 8.1b Mechanical Endovascular Reperfusion Procedures, if medical record documentation states that such a procedure was initiated later than 8 hours after hospital arrival
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Patients with ICD-10-PCS procedure codes on Table 8.1a Thrombolytic Agent Procedures or Table 8.1b Mechanical Endovascular Reperfusion Procedures, if medical record documentation states that such a procedure was initiated within 8 hours after hospital arrival |
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Delayed Endovascular Rescue Procedure
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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