Specifications Manual for Joint Commission National Quality Measures (v2019A1)
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Release Notes:
Data Element
Version 2019A1

Name:IV Alteplase Initiation
Collected For: ASR-IP-1, ASR-OP-1, ASR-OP-2, CSTK-05, STK-4, STK-OP-1
Definition:Intravenous (IV) alteplase was initiated at this hospital. IV alteplase converts plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving thrombus.
Question:Is there documentation that IV alteplase was initiated at this hospital?
Allowable Values:

Y (Yes) IV alteplase was initiated at this hospital.

N (No) IV alteplase was not initiated at this hospital, OR unable to determine from medical record documentation.

Notes for Abstraction:
  • When a “hang time” or “infusion time” for IV alteplase is documented in the medical record, select “Yes.”
  • If IV alteplase was administered at another hospital and patient was subsequently transferred to this hospital, select “No.”
  • If the patient was transferred to this hospital with IV alteplase infusing, select “No.”

Suggested Data Sources:
  • Emergency department record
  • Progress notes
  • IV flow sheets
  • Medication records
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Only Acceptable Thrombolytic Therapy for Stroke:
  • Activase
  • Alteplase
  • IV t-PA
  • Recombinant t-PA Tissue plasminogen activator
  • t-PA Tissue plasminogen activator

  • Intra-arterial (IA) t-PA
  • Thrombolytic administration to flush, open, or maintain patency of a central line, e.g., PICC line

IV Alteplase Initiation
CPT® only copyright 2019 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2019A1)
Discharges 10-01-19 through 12-31-19 (4Q19)


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