Specifications Manual for Joint Commission National Quality Measures (v2021A1)
Posted: 9/25/2020
Home » IA Alteplase or MER Initiation Time

Release Notes:
Data Element
Version 2021A1

Name:IA Alteplase or MER Initiation Time
Collected For: CSTK-05
Definition:The time (military time) for which IA alteplase or mechanical endovascular reperfusion (MER) therapy was initiated at this hospital. IA alteplase converts plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving thrombus. Reperfusion therapies also include procedures utilizing mechanical thrombectomy devices with or without pharmacological thrombolysis.
Question:What was the time of IA alteplase or MER initiation?
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 Therapy Initiation 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 Therapy Initiation Date.
Example:
Midnight or 24:00 on 11-24-20xx = 0000 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
  • 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.”
    *Example:*
    Documentation indicates the MER initiation time was 3300. No other documentation in the medical record provides a valid time. Since the MER initiation 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.”
  • The earliest time should be used. If both IA alteplase and MER were initiated in the same procedure or different procedures, select the time for the intervention that was done first.
    Example:
    • “Patient entered the interventional suite at 1130. Anesthesia start time 1145. Groin puncture documented at 1151. IA infusion at 1205. Solataire deployed at 1229; second deployment 1243; Trevo deployed at 1310.” Select 1205 for IA Alteplase or MER Initiation Time.
  • If aspiration technique was done first, then select the time associated with clot access.
  • If the time of therapy initiation is unable to be determined from medical record documentation, select “UTD.”
Suggested Data Sources:
  • Consultation notes
  • Diagnostic test reports
  • Operative notes
  • Procedure notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Locate an inclusion term in a suggested data source. Use the earliest time associated with an inclusion term that represents the IA Alteplase or MER Initiation Time.

IA Altplase:
  • Infusion time
  • Injection time
  • Bolus time

MER:
  • Catheter pass time
  • Clot access time
  • Clot engagement time
  • Deployment time
  • First pass time
  • First pull time
  • MER initiation time
  • MER start time
  • Pass time

Alternative MER initiation terms that may be used when NONE of the above are documented:
  • Anesthesia time
  • ADAPT time
  • Aspiration time
  • Groin puncture time
  • Procedure start time
  • Puncture time
  • Skin puncture time

  • Time out

IA Alteplase or MER Initiation Time
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Specifications Manual for Joint Commission National Quality Measures (v2021A1)
Discharges 01-01-21 (1Q21) through 06-30-21 (2Q21)

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