Delayed Endovascular Rescue Procedure (v2020A2)

Specifications Manual for Joint Commission National Quality Measures (v2020A2)

Posted: 10/30/2019

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Release Notes:
Data Element
Version 2020A2

Name:

Delayed Endovascular Rescue Procedure

Collected For:

CSTK-09, CSTK-11

Definition:

Endovascular treatment (EVT) with a device and/or intra-arterial (IA) thrombolysis (t-PA) that was first performed at this hospital later than 8 hours after hospital arrival.

Question:

Is there documentation in the medical record that the first endovascular treatment procedure was initiated greater than 8 hours after arrival at this hospital?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is documentation that the first endovascular treatment procedure was initiated greater than 8 hours after arrival at this hospital.

N (No) There is no documentation that the first endovascular treatment procedure was initiated greater than 8 hours after arrival at this hospital, OR unable to determine from medical record documentation.

Notes for Abstraction:

If EVT was initiated greater than 8 hours after hospital arrival AND there was no EVT procedure, i.e., mechanical embolectomy/ thrombectomy and/or IA thrombolysis (t-PA) performed during the first 8 hours after hospital arrival, then select "Yes".
Example: Patient arrives at the hospital ED on 01-11-20XX at 0013. NIHSS 2. IV t-PA given. On 01-11-20XX, patient found with slurred speech, left-sided facial droop and paresthesia. Stroke alert call at 0900. Thrombectomy performed on 01-11-20XX at 1010.
If EVT was initiated within 8 hours after hospital arrival and another EVT procedure performed later than 8 hours following hospital arrival, select "No".
Example: Patient arrives at the hospital ED on 01-15-20XX at 1513. IA t-PA initiated at 1605. Thrombectomy performed 01-17-20XX at 0640.
If unable to determine, select "No".

Suggested Data Sources:

Consultation notes
Diagnostic test reports
Operative notes
Operative report
Procedure notes
Procedure report

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
Patients with ICD-10-PCS procedure codes on Table 8.1a Thrombolytic Agent Procedures or Table 8.1b Mechanical Endovascular Reperfusion Procedures, if medical record documentation states that such a procedure was initiated later than 8 hours after hospital arrival	Patients with ICD-10-PCS procedure codes on Table 8.1a Thrombolytic Agent Procedures or Table 8.1b Mechanical Endovascular Reperfusion Procedures, if medical record documentation states that such a procedure was initiated within 8 hours after hospital arrival

Specifications Manual for Joint Commission National Quality Measures (v2020A2)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

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