Release Notes:
Data Element
Version 2018B1
| Name: | NIHSS Score Documented Closest to IA Alteplase or MER Initiation |
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| Collected For: |
CSTK-05 |
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| Definition: | The NIHSS score documented closest to IA alteplase or mechanical endovascular reperfusion (MER) therapy initiation is the last NIHSS score documented prior to IA alteplase or MER initiation (i.e., the initiation time of the intervention performed first) at this hospital. The NIHSS measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language. |
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| Question: | What is the last NIHSS score documented prior to initiation of IA alteplase or MER at this hospital? |
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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 last NIHSS score documented prior to IA alteplase or MER initiation at this hospital.
Examples:
- “Initial NIHSS score 4 documented by the ED nurse at this hospital. No other NIHSS scores were documented prior to IA alteplase or MER initiation.” Select ‘4’.
- “NIHSS score 6 prior to transfer to this hospital. IV alteplase ‘drip and ship’. Arrival Time at this hospital 2319. NIHSS score 8 at 2325 and NIHSS score 10 at 2340. IA Alteplase Initiation Time 0015.” Select ‘10’.
- “NIHSS score 10 on arrival. IV alteplase given at 0800. NIHSS score 8 at 0900. IA infusion start time 0950.” Select ‘8’.
- “IV alteplase given at a transferring hospital. Nurse documented NIHSS score 18 via telemedicine prior to arrival at this hospital. Patient went directly to OR for mechanical thrombectomy procedure. No NIHSS score documented at this hospital prior to intervention.” Select ‘18’.
- For purposes of this data element, score documentation between 0 and 42 is acceptable. Only one score may be selected. Select the last NIHSS score documented prior to the start time of IA alteplase OR first pass of a mechanical reperfusion device whichever intervention is performed first, i.e. “IA Alteplase first then MER” or “MER first then IA Alteplase”, at this hospital.
- If only one NIHSS score is documented prior to IA alteplase or MER initiation and no other score(s) are available for comparison, enter the value for that score.
- If no NIHSS score is documented prior to IA alteplase or MER initiation, select “UTD”.
- If unable to determine the last NIHSS score documented prior to IA alteplase or MER initiation, select “UTD”.
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| Suggested Data Sources: |
- Consultation notes
- History and physical
- Nursing flow sheet
- Progress notes
- Transfer sheet
- Admitting note
- Ambulance record
- Emergency room records
- 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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