Specifications Manual for Joint Commission National Quality Measures (v2018A1)
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Release Notes:
Data Element
Version 2018A1

Data Element Name: IV Thrombolytic Initiation
Collected For: ASR-IP-1, ASR-OP-1, ASR-OP-2, CSTK-05, STK-4
Definition:Intravenous (IV) thrombolytic therapy was initiated at this hospital. IV thrombolytics convert plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving thrombus. IV t-PA is the only FDA-approved IV thrombolytic for stroke.
Suggested Data Collection Question:Is there documentation that IV thrombolytic therapy was initiated at this hospital?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

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

N (No) IV thrombolytic was not initiated at this hospital, OR unable to determine from medical record documentation.

Notes for Abstraction:
  • When a “hang time” or “infusion time” for IV thrombolytic is documented in the medical record, select “Yes.”
  • If IV thrombolytic therapy was administered at another hospital and patient was subsequently transferred to this hospital, select “No.”
  • If the patient was transferred to this hospital with IV thrombolytic infusing, select “No.”

Suggested Data Sources:

  • Emergency department record
  • Progress notes
  • IV flow sheets
  • Medication records
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Only Acceptable Thrombolytic Therapy for Stroke:
  • Activase
  • Alteplase
  • IV t-PA
  • Recombinant t-PA Tissue plasminogen activator

  • Intra-arterial (IA) t-PA
  • Thrombolytic administration to flush, open, or maintain patency of a central line, e.g., PICC line

IV Thrombolytic Initiation
Specifications Manual for Joint Commission National Quality Measures (v2018A1)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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