Release Notes:
Data Element
Version 2018B
| Data Element Name: |
Positive Brain Image |
|---|
| Collected For: |
CSTK-05 |
|---|
| Definition: | Documentation of a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage following IV or IA alteplase therapy, OR mechanical endovascular reperfusion therapy initiation. The major risk of reperfusion therapy is hemorrhage |
|---|
| Suggested Data Collection Question: | Was there a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage following IV or IA alteplase therapy, or mechanical endovascular reperfusion therapy initiation? |
|---|
| Format: |
| Length: | 1 |
|---|
| Type: | Alphanumeric |
|---|
| Occurs: | 1 |
|---|
|
|---|
| Allowable Values: |
Y (YES) Parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was detected on brain imaging following IV or IA alteplase therapy, or mechanical endovascular reperfusion therapy initiation.
N (No) Parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage was not detected on brain imaging following IV or IA alteplase therapy, or mechanical endovascular reperfusion therapy initiation, OR Unable to determine (UTD) from the medical record documentation.
|
|---|
| Notes for Abstraction: |
- For purposes of this data element, do not use brain imaging reports for CT/MRI performed prior to IV or IA alteplase initiation, or mechanical endovascular reperfusion (MER) therapy. Abstract only brain imaging reports for tests done after these interventions to select ‘YES’.
- Patients with a positive finding on brain imaging of parenchymal hematoma, subarachnoid hemorrhage, and/or intraventricular hemorrhage on brain imaging following IV or IA alteplase therapy, or mechanical endovascular reperfusion therapy initiation, are acceptable to select “Yes”.
- A confirmed report is not necessary. Reports of preliminary findings within this timeframe may be used in abstraction.
- If the report documents that “hemorrhage cannot be excluded”, “cannot R/O hemorrhage”, or “findings suggestive of hemorrhage”, select “Yes”.
- When conflicting information is documented in the medical record, select ‘YES’.
- Documentation that the hemorrhage is "old", select 'NO'. Do not infer that a hemorrhage is old unless explicitly documented.
- See the inclusion list for acceptable examples of documentation of a positive finding. The list is not all inclusive.
|
|---|
| Suggested Data Sources: |
ONLY acceptable data source:
- Brain imaging reports
- Diagnostic test reports
- Radiology reports
|
|---|
| Additional Notes: |
|
|---|
| Guidelines for Abstraction: |
|---|
| Inclusion |
Exclusion |
- Bleed
- Brain hemorrhage
- Cerebral hemorrhage
- ECASS criteria PH1 or PH2
- Hemorrhage
- Hemorrhagic conversion
- Hemorrhagic expansion
- Hemorrhagic transformation
- Intracerebral hemorrhage (ICH)
- Intracranial hemorrhage
- Intraparenchymal hemorrhage
- Intraventricular hemorrhage
- Parenchymal hematoma
- Parenchymal hemorrhage
- Parenchymal intracerebral hemorrhage
- Subarachnoid hemorrhage (SAH)
|
- ECASS criteria H1 or H2
- Incidental
- Micro
- Petechial
- Punctate
- Trace
|
|
Positive Brain Image
Specifications Manual for Joint Commission National Quality Measures (v2018B)
Discharges 01-01-19 (1Q19) through 06-30-19 (2Q19)
^