Positive Brain Image (v2019A)

Specifications Manual for Joint Commission National Quality Measures (v2019A)

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Release Notes:
Data Element
Version 2019A

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

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

Specifications Manual for Joint Commission National Quality Measures (v2019A)
Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19)

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