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Release Notes:
Data Element
Version 2010A1

Data Element Name: Reason for Delay in Fibrinolytic Therapy
Collected For: AMI-7, AMI-7a,
Definition:Documentation of a reason for a delay in initiating fibrinolytic therapy after hospital arrival by a physician/advanced practice nurse/physician assistant (physician/APN/PA). System reasons for delay are NOT acceptable.

Suggested Data Collection Question:Is there a reason documented by a physician/APN/PA for a delay in initiating fibrinolytic therapy after hospital arrival?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y    (Yes)   Reason documented by a physician/APN/PA for a delay in initiating fibrinolytic therapy after hospital arrival.

N   (No)   No reason documented by a physician/APN/PA for a delay in initiating fibrinolytic therapy after hospital arrival, or unable to determine from medical record documentation.

JOINT COMMISSION NOTE TO PROGRAMMERS:
Systems may choose to incorporate logic in their data collection tools to display the measurement value (time to fibrinolysis) onscreen and enable/disable data entry to this question based on the calculated value. Refer to the algorithm of the measures for steps in deriving the calculated value. The objective is to restrict data entry to this question to cases in which the time to fibrinolytic therapy is > 30 minutes (and < or = 360 minutes) after hospital arrival.

Notes for Abstraction:
  • System reasons for delay are not acceptable, regardless of any linkage to the delay in fibrinolysis/reperfusion.
    • Equipment-related (e.g., IV pump malfunction)
    • Staff-related (e.g., waiting for fibrinolytic agent from pharmacy)
    • Consultation with other clinician
  • Documentation must be made clear somewhere in the medical record that (1) a “hold,” “delay,” or “wait” in initiating fibrinolysis/reperfusion actually occurred, AND (2) that the underlying reason for that delay was non-system in nature. Abstractors should NOT make inferences from documentation of a sequence of events alone or otherwise attempt to interpret from documentation. Clinical judgment should not be used in abstraction.
    • Examples of ACCEPTABLE documentation:
      -“Hold on fibrinolytics. Will do CAT scan to r/o bleed.”
      -“Patient waiting for family and clergy to arrive – wishes to consult with them before thrombolysis.”
      -“Fibrinolysis delayed due to need to control blood pressure before administering fibrinolysis.”
    • Exceptions: Both cardiopulmonary arrest within 30 minutes after hospital arrival and initial patient/family refusal of fibrinolysis/reperfusion are acceptable reasons for delay that do NOT require documentation that a “hold,” “delay,” or “wait” in initiating fibrinolysis actually occurred. In order for cardiopulmonary arrest within 30 minutes after hospital arrival to be considered an automatic acceptable reason for delay, documentation that it occurred within 30 minutes after hospital arrival must be CLEAR. Consider all physician/APN/PA documentation of cardiopulmonary arrest activity and use the earliest time in confirming whether cardiopulmonary arrest occurred within 30 minutes after arrival. (Determining the exact point in time the cardiopulmonary arrest occurred is not necessary.)
  • If unable to determine whether a documented reason is system in nature, select “No.”
  • Reasons for a delay in fibrinolytic therapy should be collected regardless of how soon after arrival it was ultimately initiated or how minimal the delay.

Suggested Data Sources:

PHYSICIAN/APN/PA DOCUMENTATION ONLY

  • Code sheet (if signed by physician/APN/PA
  • Consultation notes
  • Discharge summary
  • Emergency department record
  • History and physical
  • Physician orders
  • Progress notes

Excluded Data Sources:
Any documentation dated/timed after discharge, except discharge summary and operative/procedure/diagnostic test reports (from procedure done during hospital stay)

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Cardiopulmonary arrest
  • Cardiac arrest
  • Cardiopulmonary resuscitation (CPR)
  • Code
  • Defibrillation
  • Endotracheal intubation
  • Respiratory arrest
  • Ventricular fibrillation (V-fib)

  • None

Reason for Delay in Fibrinolytic Therapy
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)