Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time (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:

Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time

Collected For:

CSTK-11, CSTK-12

Definition:

The time (military time) that a Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade of 2B/3 was first documented during the mechanical thrombectomy procedure.

Question:

What was the time that a TICI 2B/3 was first documented during the mechanical thrombectomy procedure?

Format:

Length:	5 - HH-MM (with or without colon) or UTD
Type:	Time
Occurs:	1

Allowable Values:

HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine

Time must be recorded in military time format. With the exception of Midnight and Noon:

If the time is in the a.m., conversion is not required
If the time is in the p.m., add 12 to the clock time hour

Examples:

Midnight = 00:00
Noon = 12:00
5:31 am = 05:31
5:31 pm = 17:31
11:59 am = 11:59
11:59 pm = 23:59

Note:
00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.

When converting Midnight or 24:00 to 00:00, do not forget to change the Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Date.
Example:
Midnight or 24:00 on 11-24-20xx = 0000 on 11-25-20xx

Notes for Abstraction:

Use the time a TICI 2B/3 was first documented. If a discrepancy exists in time documentation from different sources, choose the earliest time. If multiple times are documented during the procedure, use the earliest time.
The procedure end time may be used if an earlier time is not documented during the procedure.
For times that include “seconds”, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00.
If the time a TICI 2B/3 was first documented is unable to be determined from medical record documentation, select “UTD”.
A grade value (e.g., 2B/3) must be documented to meet this data element. Do not infer a TICI grade based on other documentation in the medical record, e.g., TICI estimated from the dictated angiography report.
The medical record must be abstracted as documented (taken at “face value”). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select “UTD”.
Example:
Documentation indicates the Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time was 3300. No other documentation in the medical record provides a valid time. Since the Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.
Note:
Transmission of a case with an invalid time as described above will be rejected from the Joint Commission’s Data Warehouse. Use of “UTD” for Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time allows the case to be accepted into the warehouse.

Suggested Data Sources:

Consultation notes
Progress notes
Operative notes
Procedure notes

Additional Notes:

Guidelines for Abstraction:

Inclusion

Exclusion

Reperfusion time
Revascularization time
Stroke reperfusion time
TICI time

None

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

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