Release Notes:
Data Element
Version 2018B
| Data Element Name: |
Highest NIHSS Score Documented Within 36 Hours Following IA Alteplase or MER Initiation |
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| Collected For: |
CSTK-05 |
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| Definition: | The highest NIHSS score documented within 36 hours following initiation of IA alteplase or mechanical endovascular reperfusion therapy (MER). The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language. |
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| Suggested Data Collection Question: | What is the highest NIHSS score documented within 36 hours following IA alteplase or MER initiation?
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| Format: |
| Length: | 3 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Score = 0-42
UTD = Unable to Determine
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| Notes for Abstraction: |
- The NIHSS score may be documented by the physician/APN/PA or nurse (RN).
- Look for the highest NIHSS score documented in less than or equal to 36 hours following initiation of IA alteplase or MER therapy.
- For purposes of this data element, score documentation between 0 and 42 is acceptable.
- If only one NIHSS score is documented within the first 36 hours following initiation of IA alteplase or MER therapy and no other NIHSS score(s) are available for comparison, enter the value for that score.
- If multiple scores are documented within the first 36 hours following initiation of IA alteplase or MER therapy, select the highest score.
EXAMPLES:
- IA alteplase initiated at 1247 with first deployment of a mechanical reperfusion device at 1303. NIHSS Score is 10 at 1500 and 20 at 2300. Select NIHSS score of 20.
- IA alteplase infusion initiated on 9/5/20XX at 0900. NIHSS score is 8 on 9/5/20XX at 2300, 10 on 9/6/20XX at 0100, and 8 on 9/6/20XX at 0300. Select NIHSS score 10.
- MER initiated on 9/5/20XX at 0900. NIHSS score 3 on 9/6/20XX at 0900, 2 on 9/8/20XX at 0900, and 6 on 9/10/2012 at 0900. Select 3.
- If no NIHSS score is documented within 36 hours following IA alteplase or MER therapy initiation, select “UTD”.
- If unable to determine the highest score documented within 36 hours following IA alteplase or MER therapy initiation, select “UTD”.
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Nursing flow sheet
- Progress notes
- Admitting note
- Nursing assessment
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion |
Exclusion |
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None
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- Modified NIHSS scores
- Estimated NIHSS scores
- Scoring methodologies other than NIHSS
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Highest NIHSS Score Documented Within 36 Hours Following IA Alteplase or MER Initiation
Specifications Manual for Joint Commission National Quality Measures (v2018B)
Discharges 01-01-19 (1Q19) through 06-30-19 (2Q19)
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