Specifications Manual for Joint Commission National Quality Measures (v2021A)
Posted: 7/29/2020
Home » Reason for Not Administering Nimodipine Treatment

Release Notes:
Data Element
Version 2021A

Name:Reason for Not Administering Nimodipine Treatment
Collected For: CSTK-06
Definition:Reason for not administering nimodipine treatment:
  • Nimodipine allergy
  • Non-aneurysmal subarachnoid hemorrhage (SAH)
  • Reversible cerebral vasoconstriction syndrome
  • Cerebral amyloid angiopathy
  • Other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist

Nimodipine inhibits calcium transport into vascular smooth muscle cells, thereby preventing or limiting cerebral vasospasm.
Question:Is there documentation by a physician/APN/PA or pharmacist in the medical record of a reason for not administering nimodipine treatment?
Allowable Values:

Y (Yes) There is documentation of a reason for not administering nimodipine treatment.

N (No) There is no documentation of a reason for not administering nimodipine treatment, OR unable to determine from medical record documentation.
Notes for Abstraction:
  • Reasons for not administering nimodipine must be documented by the physician/APN/PA or pharmacist within 24 hours of hospital arrival. It is not necessary to review documentation outside of this timeframe.
  • The following are acceptable as stand-alone reasons for not administering nimodipine treatment – Nimodipine linkage is not needed:
    • Non-aneurysmal subarachnoid hemorrhage (SAH)
    • Reversible cerebral vasoconstriction syndrome
    • Cerebral amyloid angiopathy
  • If reasons are not mentioned in the context of nimodipine treatment, do not make inferences (e.g., do not assume that nimodipine was not administered because of hypotension unless documentation explicitly states so.)
    • Reasons must be explicitly documented (e.g., “BP 80/40 — No nimodipine.”)
    • Physician/APN/PA or pharmacist documentation of a hold on nimodipine or discontinuation of nimodipine that occurs within the first 24 hours of hospital arrival constitutes a “clearly implied” reason for not administering nimodipine treatment. A hold/discontinuation of all P.O. medications counts if nimodipine (i.e., Nimotop, Nymalize) was on order at the time of the notation.
      Documentation of a conditional hold or discontinuation of nimodipine (e.g., “Hold nimodipine if SBP < 100 mm/Hg”, “Stop nimodipine if AST > 50 IU/L”.
  • When conflicting information is documented in the medical record, select “Yes”.
  • Documentation that the patient is NPO or has a nasogastric tube (NGT) without mention that nimodipine should not be administered is insufficient. Do not infer that nimodipine is not needed unless explicitly documented.
    • Physician orders for “NPO except medications” does not count as a reason for not administering nimodipine, select “No”.
Suggested Data Sources:
  • Emergency department record
  • Nursing flow sheet
  • Progress notes
  • Medication administration record (MAR)
  • Medication reconciliation form
Additional Notes: Excluded Data Sources:
  • Any documentation dated/timed later than 24 hours after hospital arrival.
Guidelines for Abstraction:
Inclusion Exclusion
  • Patient/family refusal

Reason for Not Administering Nimodipine Treatment
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Specifications Manual for Joint Commission National Quality Measures (v2021A)
Discharges 01-01-21 (1Q21) through 06-30-21 (2Q21)


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