Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Posted: 9/2/2020
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Release Notes:
Data Element
Version 2020B2

Name:Skin Puncture Time
Collected For: CSTK-09, CSTK-12
Definition:The time (military time) of skin puncture at this hospital to access the arterial site selected for endovascular treatment of a cerebral artery occlusion.
Question:What is the time of skin puncture at this hospital to access the arterial site selected for endovascular treatment of a cerebral artery occlusion?
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 Skin Puncture 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 Skin Puncture Date.
Example:
Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx
Notes for Abstraction:
  • 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 Skin Puncture Time is unable to be determined from medical record documentation, select “UTD”.
  • 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”.
    Examples:
    Documentation indicates the Skin Puncture Time was 3300. No other documentation in the medical record provides a valid time. Since the Skin Puncture 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 Skin Puncture Time allows the case to be accepted into the warehouse.
  • Abstract the Skin Puncture Time documented for endovascular treatment of the occluded cerebral artery.”
    Examples:
    Arrival time 1400. A-line started in the emergency department at 1425. Entered interventional suite at 1600. Anesthesia start time 1607. Groin puncture at 1615. Select 1615.
  • If multiple skin puncture times are documented for the same endovascular procedure, then select the earliest time.
    • Disregard times associated with unsuccessful access of the artery.
      Example:
      Physician documents 4/20 0350 attempted groin puncture unsuccessful, followed by documentation on 4/20 0356 successful groin puncture. Select 0356.

Suggested Data Sources:
  • Consultation notes
  • Diagnostic test reports
  • Operative notes
  • Operative report
  • Procedure notes
  • Procedure report
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Carotid puncture time
  • Brachial puncture time
  • Femoral puncture time
  • Groin puncture time
  • Radial puncture time

None

Skin Puncture Time
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Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

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