Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Posted: 9/2/2020
Home » Delayed Endovascular Rescue Procedure

Release Notes:
Data Element
Version 2020B2

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

Delayed Endovascular Rescue Procedure
CPT® only copyright 2019 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)

CPT® only copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.

^