Specifications Manual for Joint Commission National Quality Measures (v2027A)
Posted: 8/7/2026

Release Notes:
Measure Information Form
Version 2027A

**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Stroke (STK)

Set Measure ID: STK-4

Performance Measure Name: Thrombolytic Therapy

Description: Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV alteplase was initiated at this hospital within 3 hours of time last known well.

Rationale: The administration of IV thrombolytics to carefully screened, eligible patients with acute ischemic stroke has been shown to be beneficial in several clinical trials (Class I, Level of Evidence A, American Heart Association/American Stroke Association (AHA/ASA), 2019). These included two positive randomized controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA) approved the use of intravenous alteplase for the treatment of acute ischemic stroke when given within 3 hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome confirmed the benefit of IV alteplase in patients treated within 3 hours of symptom onset.

The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke. More recently, guideline recommendations from the American Heart Association/American Stroke Association provide additional evidence supporting IV thrombolytic therapy initiation in time frames up to 24 hours for certain select acute ischemic stroke (AIS) patients meeting very specific clinical criteria. As the NINDS investigators concluded, guidelines continue to reinforce that patient outcomes are better with faster administration. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment, (Prabhakaran, S., et al., 2026).

Although the benefit of IV thrombolytics has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for therapy. In March 2025, IV tenecteplase (TNK) received FDA-approval for the treatment of AIS in adults. The approval is based on a large multi-center non-inferiority study demonstrating that the efficacy of TNK and alteplase are comparable. Symptomatic intracranial hemorrhage (ICH) is a potential complication with both agents. However, a systematic review of 26 studies comparing IV TNK with alteplase suggests slightly less risk of an event (RR 0.89, 95% CI, 0.65-1.23) with TNK (Martin, 2025). Either IV TNK at a dose of 0.25mg/kg body weight (max dosage 25 mg) or IV alteplase at 0.9mg/kg body weight are recommended for AIS patients eligible for therapy within 4.5 hours of last known well to improve functional outcomes. However, the single bolus-based approach used with TNK may improve the timeliness of administration and shorten door-to-needle (DTN) and door-in-door-out (DIDO) times (Prabhakaran, S. et al., 2026).

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Acute ischemic stroke patients for whom IV alteplase was initiated at this hospital within 3 hours (less than or equal to 180 minutes) of time last known well.
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: Acute ischemic stroke patients whose time of arrival is within 2 hours (less than or equal to 120 minutes) of time last known well.
Included Populations: Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A, Table 8.1

Excluded Populations:
  • Patients less than 18 years of age
  • Patients who have a Length of Stay greater than 120 days
  • Patients enrolled in clinical trials
  • Patients admitted for Elective Carotid Intervention
  • Time Last Known Well to arrival in the emergency department greater than 2 hours
  • Patients with a documented Reason For Extending the Initiation of IV Alteplase
  • Patients with a documented Reason For Not Initiating IV Alteplase

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest. This approach provides opportunities for improvement at the point of care/service. However, complete documentation includes the principal or other ICD-10 diagnosis and procedure codes, which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:
  • Demaerschalk, B. M., Kleindorfer, D. O., Adeoye, O. M., Demchuk, A. M., Fugate, J. E., Grotta, J. C., Khalessi, A. A., Levy, E. I., Palesch, Y. Y., Prabhakaran, S., Saposnik, G., Saver, J. L., & Smith, E. E. (2016). Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 47 (2), 581–641. https://doi.org/10.1161/STR.0000000000000086
  • Grotta, J. C., & Haley, E. C., Jr. (2025). Food and Drug Administration approval of tenecteplase: What this means for the field of acute stroke treatment. Stroke: Vascular and Interventional Neurology, 5 (4). https://doi.org/10.1161/SVIN.125.001824.
  • Martin, S. S., Aday, A. W., Allen, N. B., Almarzooq, Z. I., Anderson, C. A. M., Arora, P., … Palaniappan, L. P. (2025). 2025 heart disease and stroke statistics: A report of US and global data from the American Heart Association. Circulation, 151, e333–e334.
  • Palaniappan, L. P., Allen, N. B., Almarzooq, Z. I., Anderson, C. A. M., Arora, P., Avery, C. L., Baker-Smith, C. M., Bansal, N., Currie, M. E., Earlie, R. S., Fan, W., Fetterman, J. L., Barone Gibbs, B., Heard, D. G., Hiremath, S., Hong, H., Hyacinth, H. I., Ibeh, C., Jiang, T., … Khan, S. S. (2026). 2026 heart disease and stroke statistics: A report of U.S. and global data from the American Heart Association. Circulation. Advance online publication. https://doi.org/10.1161/CIR.0000000000001412.
  • Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al., on behalf of the American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e10–e11, e26–e30.
  • Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke—A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50 (12), e344–e418.
  • Prabhakaran, S., Gonzalez, N. R., Zachrison, K. S., Adeoye, O., Alexandrov, A. W., Ansari, S. A., Chapman, S., Czap, A. L., Dumitrascu, O. M., Ishida, K., Jadhav, A. P., Johnson, B., Johnston, K. C., Khatri, P., Kimberly, W. T., Lee, V. H., Leslie-Mazwi, T. M., Mac Grory, B., Madsen, T. E., Menon, B., Mistry, E. A., Park, S., Parker, S., Pérez de la Ossa, N., Reeves, M., Saiz, T., Scott, P. A., Schwartzberg, D., Sheth, S. A., Sporns, P. B., Times, S., Tjoumakaris, S., Wolfe, S. Q., & Yaghi, S.; Peer Review Committee Collaborators. (2026). 2026 guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. Advance online publication. https://doi.org/10.1161/STR.0000000000000513
  • U.S. Food and Drug Administration. (2015). Label: Activase (alteplase).
  • U.S. Food and Drug Administration. (2025). TNKase (tenecteplase) label. https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/103909s5197lbl.pdf

Measure Algorithm:
Graphic depiction of the Measure Algorithm. Refer to the Algorithm Narrative for each detailed step.

Graphic depiction of the Measure Algorithm. Refer to the Algorithm Narrative for each detailed step.

STK-4: Algorithm Narrative

STK-4: Thrombolytic Therapy

Numerator: Acute ischemic stroke patients for whom IV alteplase therapy was initiated at this hospital within 3 hours (less than or equal to 180 minutes) of time last known well.
Denominator: Acute ischemic stroke patients whose time of arrival is within 2 hours (less than or equal to 120 minutes) of time last known well.

Variable Key : Timing I, Timing II

1. Start processing. Run cases, which are included in the Stroke Initial Patient Population and pass the edits defined in the Clinical Data Processing Flow, through this measure.

2. Check ICD-10-CM Principal Diagnosis Code
  1. If none of the ICD-10-CM Principal Diagnosis codes are on Table 8.1, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
  2. If at least one of the ICD-10-CM Principal Diagnosis codes is on Table 8.1, continue processing and proceed to check ED Patient.

3. Check ED Patient.
  1. If ED Patient is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If ED Patient equals N, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
  3. If ED Patient equals Y, continue processing and proceed to check Clinical Trial.

4. Check Clinical Trial.
  1. If Clinical Trial is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If Clinical Trial equals Y, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
  3. If Clinical Trial equals N, continue processing and proceed to check Elective Carotid Intervention.

5. Check Elective Carotid Interventions.
  1. If Elective Carotid Intervention is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If Elective Carotid Intervention equals Y, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
  3. If Elective Carotid Intervention equals N, continue processing and proceed to check Arrival Date.

6. Check Arrival Date.
  1. If Arrival Date is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If Arrival Date equals Unable to Determine (UTD), the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.
  3. If Arrival Date is Non-UTD value, continue processing and proceed to check Arrival Time.

7. Check Arrival Time.
  1. If Arrival Time is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If Arrival Time equals UTD, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.
  3. If Arrival Time is Non-UTD value, continue processing and proceed to check Last Known Well.

8. Check Last Know Well.
  1. If Last Know Well is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If Last Know Well equals N, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
  3. If Last Know Well equals Y, continue processing and proceed to check Date Last Know Well.

9. Check Date Last Know Well.
  1. If Date Last Know Well is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If Date Last Know Well equals UTD, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.
  3. If Date Last Know Well is Non-UTD value, continue processing and proceed to check Time Last Know Well.

10. Check Time Last Know Well.
  1. If Time Last Know Well is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If Time Last Know Well equals UTD, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.
  3. If Time Last Know Well is Non-UTD value, continue processing and proceed to calculate Timing I.

11. Calculate Timing I (in minute). Timing I (in minute) equals Arrival Date and Arrival Time minus Date Last Known Well and Time Last Known Well.

12. Check Timing I
  1. If Timing I is less than 0 minutes, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If Timing I is greater than 120 minutes, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
  3. If Timing I is greater than or equal to 0 minutes and less than or equal to 120 minutes, continue processing and proceed to check IV Alteplase Initiation.

13. Check IV Alteplase Initiation.
  1. If IV Alteplase Initiation is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If IV Alteplase Initiation equals N, the case will continue processing and proceed to check Step 14 Reason for Not Initiating IV Alteplase.
  3. If IV Alteplase Initiation equals Y, the case will proceed to check Step 15 IV Alteplase Initiation Date

14. Check Reason for Not Initiating IV Alteplase.
  1. If Reason for Not Initiating IV Alteplase is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If Reason for Not Initiating IV Alteplase equals Y, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
  3. If Reason for Not Initiating IV Alteplase equals N, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.

15. Check IV Alteplase Initiation Date.
  1. If IV Alteplase Initiation Date is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If IV Alteplase Initiation Date equals UTD, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.
  3. If IV Alteplase Initiation Date is Non-UTD value continue processing and proceed to check IV Alteplase Initiation Time.

16. Check IV Alteplase Initiation Time.
  1. If IV Alteplase Initiation Time is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If IV Alteplase Initiation Time equals UTD, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.
  3. If IV Alteplase Initiation Time is Non-UTD value, continue processing and proceed to calculate Timing II.

17. Calculate Timing II (in minute). Timing II (in minute) equals IV Alteplase Initiation Date and IV Alteplase Initiation Time minus Date Last Known Well and Time Last Known Well.

18. Check Timing II
  1. If Timing II is less than 0 minutes, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If Timing II is greater than 270 minutes, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.
  3. If Timing II is greater than or equal to 0 minutes and less than or equal to 270 minutes, continue processing and proceed to check Timing II.

19. Check Timing II
  1. If Timing II is greater than or equal to 0 minutes and less than or equal to 180 minutes, the case will proceed to a Measure Category Assignment of E and will be in the numerator population, Stop processing
  2. If Timing II is greater than 180 minutes and less than or equal to 270 minutes, continue processing and proceed to check Reason for Extending the Initiation of IV Alteplase.

20. Check Reason for Extending the Initiation of IV Alteplase.
  1. If Reason for Extending the Initiation of IV Alteplase is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Stop processing.
  2. If Reason for Extending the Initiation of IV Alteplase equals Y, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Stop processing.
  3. If Reason for Extending the Initiation of IV Alteplase equals N, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Stop processing.

Measure Information Form STK-4
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Specifications Manual for Joint Commission National Quality Measures (v2027A)
Discharges 01-01-2027 (1Q27) through 06-30-2027 (2Q27)

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