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

Data Element Name: Reason for Extending the Initiation of IV Thrombolytic
Collected For: ASR-IP-1, ASR-OP-1, STK-4
Definition:Reasons for extending the initiation of IV thrombolytic to 3 to 4.5 hours.
  • Documentation of treatment to lower blood pressure prior to IV thrombolytic initiation
  • Documentation of patient/family refusal of IV thrombolytic which was recanted/reversed prior to IV thrombolytic initiation
  • Documentation of cardiac arrest, respiratory arrest, cardiopulmonary resuscitation, defibrillation, or intubation in the emergency department prior to IV thrombolytic initiation
  • Other reasons for extending the initiation of IV thrombolytics to 3 to 4.5 hours documented by physician/APN/PA or pharmacist
Suggested Data Collection Question:Is there documentation on the day of or day after hospital arrival of a reason for extending the initiation of IV thrombolytic to 3 to 4.5 hours of Time Last Known Well?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes)     There is documentation on the day of or the day after hospital arrival of a reason for extending the initiation of IV thrombolytic to 3 to 4.5 hours of Time Last Known Well.

N (No)     There is no documentation on the day of or day after hospital arrival of a reason for extending the initiation of IV thrombolytic to 3 to 4.5 hours of Time Last Known Well, OR unable to determine from the medical record documentation.
Notes for Abstraction:
  • Documentation of a reason for extending the initiation of IV thrombolytic to 3 to 4.5 hours must be done on the day of or the day after hospital arrival and must refer to the time period prior to IV thrombolytic initiation. It is not necessary to review documentation outside of this timeframe to answer this data element.
  • “Other” reasons for extending the initiation of IV thrombolytic therapy to 3 to 4.5 hours must be documented by a physician/APN/PA or pharmacist.
    EXCEPTION:
    Nursing documentation of a telemedicine/teleneurology reason for extending the initiation of IV thrombolytic therapy to 3 to 4.5 hours is acceptable.
  • The following are acceptable as stand-alone reasons for extending the initiation of IV thrombolytics – IV thrombolytic therapy linkage is not needed:
    • Documentation of treatment to lower blood pressure, (e.g. nicardipine, hydralazine), prior to IV thrombolytic initiation
    • Documentation of patient/family refusal of IV thrombolytic which was recanted/reversed prior to IV thrombolytic initiation
    • Documentation of cardiac arrest, respiratory arrest, cardiopulmonary resuscitation, defibrillation, or intubation in the emergency department prior to IV thrombolytic initiation
  • If “other” reasons are not mentioned in the context of IV thrombolytics, do not make inferences (e.g., do not assume that IV thrombolytic was initiated in 3 to 4.5 hours because patient consent could not be obtained from family in 3 hours unless explicitly documented).
    Examples:
    • Documentation to initiate IV thrombolytic for worsening symptoms following documentation to not give tPA because symptoms resolved after hospital arrival, select “Yes.”
    • NIHSS score of 1 on arrival. IV thrombolytic ordered 4 hours after hospital arrival, select “No.”
  • System reasons are not acceptable as “other” reasons, regardless of any linkage to IV thrombolytics:
    • Equipment-related (e.g., CT not available, IV pump malfunction)
    • Pharmacy-related (e.g., thrombolytic agent not available from pharmacy)
    • Staff-related (e.g., unable to contact consulting MD)
Suggested Data Sources:

  • Consultation notes
  • Emergency department record
  • History and physical
  • Nursing notes
  • Progress notes
  • Physician orders
  • Medical transport records
  • Medication reconciliation form
  • Transfer Form
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None
  • Delay in hospital arrival greater than 2 hours
  • Delay in stroke diagnosis
  • Hold IV thrombolytic without a documented reason
  • No IV access

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