Time to Intravenous Thrombolytic Therapy

CBE ID

1952

Endorsement Status

Endorsed

1.0 New or Maintenance

Maintenance

Previous Endorsement Cycle

Fall 2019

Is Under Review

Next Maintenance Cycle

Spring 2026

1.6 Measure Description

Percent of acute ischemic stroke patients receiving intravenous alteplase therapy during the hospital stay who have a time from hospital arrival to initiation of thrombolytic therapy (door-to-needle time) of 60 minutes or less

Measure Specs(active tab)
Scientific Acceptability
Use & Usability
Comments

Measure Specs

General Information(active tab)
Numerator
Denominator
Exclusions
Measure Record
Point of Contact

General Information

1.7 Measure Type

Process

1.3 Electronic Clinical Quality Measure (eCQM)

1.8 Level of Analysis

Facility

Numerator

1.14 Numerator

Patients who receive IV alteplase at my hospital within 60 minutes after arrival

Denominator

1.15 Denominator

All patients with a final clinical diagnosis of ischemic stroke who received IV alteplase at my hospital

Exclusions

Denominator exclusions:
• Age < 18 years

• Stroke occurred after hospital arrival (in ED/Obs/inpatient)

• Patients whose date/time of ED arrival and/or date/time of IV alteplase administration is blank, unknown, or MM/DD/YYYY only.

• Patients with a negative calculated time difference

• Patients with a Date Last Known Well, but no time Last Known Well

• Patients that receive IV alteplase greater than 4.5 hours after Last Known Well

• Patients who received IV alteplase at an outside hospital or by EMS/Mobile Stroke Unit

• Clinical Trial

Denominator exceptions:
• Patients who received IV alteplase greater than 60 minutes after arrival and have a documented Eligibility or Medical Reason for delay in treatment