Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
Home » Reason for Extending the Initiation of IV Alteplase

Release Notes:
Data Element
Version 2020B

Name:Reason for Extending the Initiation of IV Alteplase
Collected For: ASR-IP-1, ASR-OP-1, STK-4
Definition:Reasons for extending the initiation of IV alteplase to 3 to 4.5 hours.
  • Documentation of treatment to lower blood pressure prior to IV alteplase initiation
  • Documentation of patient/family refusal of IV alteplase which was recanted/reversed prior to IV alteplase initiation
  • Documentation of cardiac arrest, respiratory arrest, cardiopulmonary resuscitation, defibrillation, or intubation in the emergency department prior to IV alteplase initiation
  • Other reasons for extending the initiation of IV alteplase to 3 to 4.5 hours documented by physician/APN/PA or pharmacist
Question:Is there documentation on the day of or day after hospital arrival of a reason for extending the initiation of IV alteplase to 3 to 4.5 hours of Time Last Known Well?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes)     There is documentation on the day of or the day after hospital arrival of a reason for extending the initiation of IV alteplase to 3 to 4.5 hours of Time Last Known Well.

N (No)     There is no documentation on the day of or day after hospital arrival of a reason for extending the initiation of IV alteplase to 3 to 4.5 hours of Time Last Known Well, OR unable to determine from the medical record documentation.
Notes for Abstraction:
  • Documentation of a reason for extending the initiation of IV alteplase to 3 to 4.5 hours must be done on the day of or the day after hospital arrival and must refer to the time period prior to IV alteplase initiation. It is not necessary to review documentation outside of this timeframe to answer this data element.
  • “Other” reasons for extending the initiation of IV alteplase therapy to 3 to 4.5 hours must be documented by a physician/APN/PA or pharmacist.
    EXCEPTION:
    Nursing documentation of a telemedicine/teleneurology reason for extending the initiation of IV alteplase therapy to 3 to 4.5 hours is acceptable.
  • The following are acceptable as stand-alone reasons for extending the initiation of IV alteplase – IV alteplase therapy linkage is not needed:
    • Documentation of treatment to lower blood pressure, (e.g. nicardipine, hydralazine), prior to IV alteplase initiation
    • Documentation of patient/family refusal of IV alteplase which was recanted/reversed prior to IV alteplase initiation
    • Documentation of cardiac arrest, respiratory arrest, cardiopulmonary resuscitation, defibrillation, or intubation in the emergency department prior to IV alteplase initiation
  • If “other” reasons are not mentioned in the context of IV alteplase, do not make inferences (e.g., do not assume that IV alteplase was initiated in 3 to 4.5 hours because patient consent could not be obtained from family in 3 hours unless explicitly documented).
    Examples:
    • Documentation to initiate IV alteplase for worsening symptoms following documentation to not give tPA because symptoms resolved after hospital arrival, select “Yes.”
    • NIHSS score of 1 on arrival. IV alteplase ordered 4 hours after hospital arrival, select “No.”
  • System reasons are not acceptable as “other” reasons, regardless of any linkage to IV alteplase:
    • Equipment-related (e.g., CT not available, IV pump malfunction)
    • Pharmacy-related (e.g., alteplase not available from pharmacy)
    • Staff-related (e.g., unable to contact consulting MD)
Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Nursing notes
  • Progress notes
  • Physician orders
  • Medical transport records
  • Medication reconciliation form
  • Transfer Form
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Thrombolytic therapy
  • t-PA
  • Delay in hospital arrival greater than 2 hours
  • Delay in stroke diagnosis
  • Hold IV alteplase without a documented reason
  • No IV access

Reason for Extending the Initiation of IV Alteplase
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Specifications Manual for Joint Commission National Quality Measures (v2020B)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

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