Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival

Last updated: May 4, 2017

CMS Measure ID: CMS60v4
Version: 4
NQF Number: 0164
Measure Description:

Acute myocardial infarction (AMI) patients with ST-segment elevation on the ECG closest to arrival time receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less.

Initial Patient Population:

Patients age 18 and older at the time of ED visit or hospital admission with a principal diagnosis of Acute Myocardial Infarction (AMI) with hospital stays <= 120 days during the measurement year.

Denominator Statement:

Includes Initial Population, and patients with an ECG result of acute or evolving MI, who received fibrinolytic therapy 360 minutes starting after the hospital arrival.

Denominator Exclusions:
  • Patients received as a transfer from an inpatient or outpatient department of another hospital.
  • Patients received as a transfer from the emergency/observation department of another hospital.
  • Patients received as a transfer from an ambulatory surgery center.
Numerator Statement:

AMI patients whose time from hospital arrival to fibrinolysis is 30 minutes or less.

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

Patients who did not receive fibrinolytic therapy within 30 minutes and had a documented reason for delay in fibrinolytic therapy. Or who had one of the following procedures performed: Aortic balloon pump insertion; Endotracheal Intubation; or Ventricular Assist Device placement.

Measure Steward: Centers for Medicare & Medicaid Services
Domain: Effective Clinical Care
Short Name: AMI7a
Next Version: Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
Previous Version: Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
Measure Score: Proportion
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

To identify the ECG closest to the hospital arrival, the denominator will identify the most recent ECG performed that starts less than 1 hour prior to the emergency department (ED) or inpatient encounter OR the first ECG performed that starts after the ED or inpatient encounter started.

Denominator element guidance:

For the denominator data element Diagnostic Study, Performed: Electrocardiogram (ECG) (result: Acute or Evolving MI). EHR implementations will need to develop mechanisms to capture ECG findings to support denominator criteria for this measure. The measure specification indicates allowable findings. The source of the ECG results should be a physician/APN/PA (rather than the ECG machine's computerized results).

Numerator element guidance:

This measure expects fibrinolytic therapy within 30 minutes of hospital arrival. Those patients receiving fibrinolysis greater than 30 minutes after arrival may be excluded from the denominator only if there is a documented reason for a delay or documented occurrence of intubation, cardiopulmonary arrest or mechanical circulatory assist device placement within the first 30 minutes after arrival. Patients receiving fibrinolysis greater than 30 minutes after arrival and with no reason provided are not compliant with the numerator criteria and will remain in the denominator.

Exclusion element guidance:

Transfers from another hospital are excluded since care may have been delivered in the other setting. Transfers from those hospitals are considered exclusions regardless of whether the receiving hospital has the same or different hospital unique identifier as the transferring hospital.

Exception element guidance:

Medical or patient reasons for not performing a procedure or giving a medication are categories for valid medical or patient reasons that are not specifically listed in the exclusion section of the measure. Each is expected to be captured and made available for measurement or clinical decision support within the EHR workflow but the exact method or location of capture is a local or vendor decision.

Denominator, Numerator, Exclusion and Exception element guidance:

The criteria indicate scenarios in which the patient is admitted to the hospital directly or the patient is admitted from the Emergency Department (ED). The calculation is to indicate the timing from arrival at the facility to the occurrence of an event.

Specifications

Release Notes

Header

  • Copyright updated.
  • Disclaimer updated.
  • eMeasure version number incremented.
  • Updated Guidance in the header to align with the measure logic.
  • Updated Initial Population, Denominator, Denominator Exclusions and Denominator Exceptions to be consistent across hospital measures and align with logic.

Logic

  • Added a timing constraint to 'Encounter, Performed: Emergency Department Visit' and removed Occurrencing to constrain the time as intended.
  • Added logic to include a diagnosis of active AMI that starts during the ED visit to capture the start of the diagnosis.
  • Changed data type of 'Result' or 'Finding' to 'Performed'.
  • Condensed and combined the two sections of logic in the Denominator stating: AND NOT: AND: 'Occurrence A of Diagnostic Study, Result: Hospital Measures-ECG (result: 'Hospital Measures-Acute or Evolving MI')' AND: 'Occurrence A of Diagnostic Study, Result: Hospital Measures-ECG (result: 'NSTEMI')'. The new logic reads: AND NOT: 'Occurrence A of Diagnostic Study, Performed: Electrocardiogram (ECG) (result: STEMI Exclusions)'. Note: NSTEMI value set name changed to STEMI Exclusions to better describe its contents.
  • Introduced $ReasonForNoFibrinolyticTherapy and $AnotherHospitalOrHealthcareFacility to consolidate and simplify logic.
  • Introduced function 'satisfies all' to specify that qualifying events must meet all conditions from a set of conditions or 'satisfies any' to specify that qualifying events must meet at least one condition from a set of conditions to streamline expression logic.
  • Introduced occurrencing on variables to enforce that the same instance of a clinical event is used throughout the measure when the logic within the variable does not limit the event to a single instance, e.g., FIRST or MOST RECENT.
  • Introduced variable $EncounterInpatient to allow re-use of logical expressions and reduce redundancy/complexity.
  • Medication, Administered: Fibrinolytic Therapy' changed from hours to minutes to ensure the timing is captured as the measure intends.
  • Removed 'Clinical Trial Participant' logic due to the inability to capture clinical trials that are specific to the measure.
  • Removed Denominator Exception: Medication, Administered not done: Medical Reason' for 'Fibrinolytic Therapy' and 'Medication, Administered not done: Patient Refusal' for 'Fibrinolytic Therapy' to eliminate redundant logic.
  • Replaced 'ends before start' with 'ends before or concurrent with start of' to align across measures (when appropriate for measure intent).
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.
  • The top level logical operator for the Numerator Exclusions, Denominator Exclusions, Denominator Exceptions, and Measure Population Exclusions defaults to 'OR'.

Value Sets

  • Value set Acute Myocardial Infarction (AMI) (OID 2.16.840.1.113883.3.666.5.3011): Added 29 SNOMED codes. Updated name from Hospital Measures - AMI to Acute Myocardial Infarction (AMI).
  • Value set Acute or Evolving MI (OID 2.16.840.1.113883.3.666.5.3022): Deleted 1 SNOMED code and added 4 ICD10CM and 15 SNOMED codes. Updated value set name from Hospital Measures-Acute or Evolving MI to Acute or Evolving MI.
  • Value set Ambulatory surgical center (OID 2.16.840.1.113883.3.666.5.687): Updated value set name from Hospital Measures-Ambulatory surgical center to Ambulatory surgical center.
  • Value set Aortic balloon pump insertion (OID 2.16.840.1.113883.3.666.5.1151): Added 4 SNOMED codes (16965008, 175113001, 432375008, 442807006), 2 ICD10PCS codes (5A02110, 5A02210), and 1 ICD9CM code (37.61). Updated value set name from Hospital Measures-Aortic balloon pump insertion to Aortic balloon pump insertion.
  • Value set Cardiopulmonary arrest (OID 2.16.840.1.113883.3.666.5.748): Added 6 ICD10CM, 2 ICD9CM, and 10 SNOMED codes. Updated value set name from Hospital Measures-Cardiopulmonary arrest to Cardiopulmonary arrest.
  • Value set Clinical Trial Participant (OID 2.16.840.1.113883.3.526.2.643): Removed value set from this measure.
  • Value set Electrocardiogram (ECG) (OID 2.16.840.1.113883.3.666.5.735): Deleted 1 ICD10CM code (R94.31) and 1 ICD9CM code (794.31) to align with the intent of the measure. Updated value set name from Hospital-Measure -ECG to Electrocardiogram (ECG).
  • Value set Endotrachael Intubation (OID 2.16.840.1.113762.1.4.1045.69): Added 3 ICD10PCS codes (5A1935Z, 5A1945Z, 5A1955Z), 6 SNOMED codes (232675003, 232678001, 232680007, 232682004, 243141005, 418613003), and 4 ICD9CM codes (96.04, 96.70, 96.71, 96.72). Deleted 2 SNOMED codes (225719006, 30963003).
  • Value set Fibrinolytic Therapy (OID 2.16.840.1.113883.3.666.5.736): Deleted 1 RXNORM code (387020). Updated value set name from Hospital Measures-Fibrinolytic Therapy to Fibrinolytic Therapy.
  • Value Set Medical Reason (OID 2.16.840.1.113883.3.117.1.7.1.473): Removed value set from this measure.
  • Value set Patient Refusal (OID 2.16.840.1.113883.3.117.1.7.1.93): Removed value set from this measure.
  • Value set PCI (OID 2.16.840.1.113762.1.4.1045.67): Deleted 4 SNOMED codes (14201006, 446878003, 5431005, 68457009).
  • Value set STEMI Exclusions (OID 2.16.840.1.113762.1.4.1045.36): Added 1 ICD9CM code (410.70) and 2 SNOMED codes (703360004, 70422006). Updated value set name from NSTEMI to STEMI Exclusions.
  • Value set Transfer From Emergency Department (ED) Locations (OID 2.16.840.1.113883.3.666.5.3006): Deleted 19 SNOMED codes and added 2 SNOMED codes (225728007, 73770003). Updated value set name from Hospital-Measure (ED) Locations to Transfer From Emergency Department (ED) Locations.
  • Value set Transfer from Inpatient (OID 2.16.840.1.113883.3.666.5.3013): Deleted 12 SNOMED codes and added 2 SNOMED codes (434771000124107, 440654001). Updated value set name from Hospital Measures-Acute care hospital to Transfer From Inpatient.
  • Value set Transfer From Outpatient (OID 2.16.840.1.113883.3.67.1.101.950): Deleted 27 SNOMED codes and added 1 SNOMED codes (440655000). Updated value set name from Hospital Measures-Hospital outpatient department to Transfer From Outpatient.
  • Value set Ventricular Assist Device placement (OID 2.16.840.1.113883.3.666.5.3015): Deleted 7 ICD10PCS codes, 3 ICD9CM codes, and 11 SNOMED codes and added 1 ICD9CM and 2 SNOMED codes. Updated value set name from Hospital Measures-Ventricular Assist Device placement to Ventricular Assist Device placement.

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