Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
Home » Reason for Not Initiating IV Alteplase

Release Notes:
Data Element
Version 2020B

Name:Reason for Not Initiating IV Alteplase
Collected For: ASR-IP-1, ASR-OP-1, STK-4
Definition:Reasons for not initiating IV alteplase.
  • Documentation that intravenous (IV) or intra-arterial (IA) alteplase was initiated by a transferring hospital or emergency medical staff (EMS) prior to hospital arrival
  • Documentation of patient/family refusal of IV alteplase
  • Documentation of a National Institutes for Health Stroke Scale (NIHSS) score of zero in the emergency department
  • Documentation by a physician/APN/PA that the patient has “no neurological deficit” or “normal neurological exam” in the emergency department
  • Documentation of cardiac arrest, respiratory arrest, cardiopulmonary resuscitation, defibrillation, or intubation in the emergency department
  • Comfort Measures Only documented by a physician/APN/PA
  • Other reasons for not initiating IV alteplase documented by physician/APN/PA or pharmacist
Question:Is there documentation on the day of or day after hospital arrival of a reason for not initiating IV alteplase?
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 not initiating IV alteplase.

N (No) There is no documentation on the day of or day after hospital arrival of a reason for not initiating IV alteplase, OR unable to determine from the medical record documentation.
Notes for Abstraction:
  • Documentation of a reason for not initiating IV alteplase must be done on the day of or the day after hospital arrival. It is not necessary to review documentation outside of this timeframe to answer this data element.
  • “Other” reasons for not initiating IV alteplase must be documented by a physician/APN/PA or pharmacist.
    EXCEPTION:
    Nursing documentation of a telemedicine/teleneurology reason for not initiating IV alteplase is acceptable.
  • The following are acceptable as stand-alone reasons for not initiating IV alteplase – IV alteplase linkage is not needed:
    • Documentation that intravenous (IV) or intra-arterial (IA) alteplase was initiated by a transferring hospital or EMS prior to hospital arrival
    • Documentation of patient/family refusal of IV alteplase
    • Documentation of NIHSS score of zero in the emergency department
    • Documentation by a physician/APN/PA that the patient has “no neurological deficit” or “normal neuro exam” in the emergency department
    • Documentation of cardiac arrest, respiratory arrest, cardiopulmonary resuscitation, defibrillation, or intubation in the emergency department
    • Comfort Measures Only documented by a physician/APN/PA
  • 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 not initiated because of a bleeding disorder unless explicitly stated in the documentation).
    Acceptable examples (select “Yes”):
    • “Patient with Stage IV cancer – No t-PA”
    • “Increased risk of bleeding – hold t-PA for further evaluation”
      Unacceptable examples (select “No”):
    • “Age"
    • "Stroke too mild"
    • "Stroke too severe"
    • "Symptoms resolving”
    • “No gait deficit”
    • “Metastatic brain tumor”
  • Documentation by a physician/APN/PA or pharmacist that the patient is not a t-PA candidate, not eligible for IV alteplase, thrombolytics are not indicated, or t-PA is contraindicated, without mention of the underlying reason, is acceptable as an “other” reason if it is documented on the day of or day after hospital arrival.
  • Reason documentation which refers to intravenous medications only (e.g., “Hold IV medications,” “No IVs”), is not acceptable.
  • 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
  • History and physical
  • Nursing notes
  • Progress notes
  • Physician orders
  • Medical transport records
  • Medication reconciliation form
  • Transfer Form
  • Emergency room record
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 Not Initiating 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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