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Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED)

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Table Options
Measure Information 2023 Reporting Period 2024 Reporting Period 2025 Reporting Period
Title Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED) Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED) Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED)
CMS eCQM ID CMS996v3 CMS996v4 CMS996v5
Short Name OP-40 (STEMI)

OP-40 (STEMI)

CBE ID* 3613e 3613e 3613e
Measure Steward Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS)
Description

Percentage of emergency department (ED) encounters for patients 18 years and older with a diagnosis of ST-segment elevation myocardial infarction (STEMI) that received appropriate treatment, defined as fibrinolytic therapy within 30 minutes of ED arrival, percutaneous coronary intervention (PCI) within 90 minutes of ED arrival, or transfer within 45 minutes of ED arrival

Percentage of emergency department (ED) encounters for patients 18 years and older with a diagnosis of ST-segment elevation myocardial infarction (STEMI) that received appropriate treatment, defined as fibrinolytic therapy within 30 minutes of ED arrival, percutaneous coronary intervention (PCI) within 90 minutes of ED arrival, or transfer within 45 minutes of ED arrival

Percentage of emergency department (ED) encounters for patients 18 years and older with a diagnosis of ST-segment elevation myocardial infarction (STEMI) that received appropriate treatment, defined as fibrinolytic therapy within 30 minutes of ED arrival, percutaneous coronary intervention (PCI) within 90 minutes of ED arrival, or transfer within 45 minutes of ED arrival

Measure Scoring Proportion measure Proportion measure Proportion measure
Measure Type Process Process Process
Stratification *See CMS996v3.html

None

None

Risk Adjustment *See CMS996v3.html

None

None

Rationale *See CMS996v3.html

Studies have shown that delays in the treatment of acute myocardial infarction (AMI) leads to increased risk of in-hospital mortality and morbidity, with nearly two lives per 1,000 patients lost per hour of delay in treatment (Sohlpour & Yusuf, 2014; Fibrinolytic Therapy Trialists’ Collaborative Group, 1994). For patients receiving fibrinolytic therapy, the American Heart Association (AHA) estimates that 65 lives will be saved per 1,000 patients if treatment is administered within the first hour of symptom onset, and 131 lives will be saved per 1,000 patients treated if fibrinolytic therapy is delivered within the first three hours (O’Connor et al., 2010).

The total ischemic time—that is, the time from onset of STEMI symptoms to the initiation of some form of reperfusion therapy—is the principal determinant of health outcomes for patients with an AMI, so timely care is essential to minimize disease morbidity and mortality. Primary PCI is the preferred treatment approach, with guidelines recommending initiation of PCI within 120 minutes from first medical contact (O’Gara et al., 2013). In situations where it is unlikely or impossible for a patient to receive primary PCI within the 120-minute timeframe, fibrinolytic therapy may be used for reperfusion and should be rapidly administered to reduce mortality and minimize morbidity; guidelines recommend that fibrinolytic therapy administration occur within 30 minutes of hospital arrival; this may also require rapid transfer for PCI (O’Gara et al., 2013).

Implementation of an eCQM addressing appropriateness and effectiveness of care for STEMI patients in the ED has the potential to improve the delivery of care furthering alignment with current clinical practice guidelines, while reducing adverse health outcomes such as mortality, bleeding events, and reinfarction. Use of the proposed eCQM could also reduce burden on facilities currently measured using the chart-abstracted Fibrinolytic Therapy Received within 30 Minutes of ED Arrival (OP-2) measure and broaden the population for which performance scores could be publicly reported.

Studies have shown that delays in the treatment of acute myocardial infarction (AMI) leads to increased risk of in-hospital mortality and morbidity, with nearly two lives per 1,000 patients lost per hour of delay in treatment (Sohlpour & Yusuf, 2014; Fibrinolytic Therapy Trialists’ Collaborative Group, 1994). For patients receiving fibrinolytic therapy, the American Heart Association (AHA) estimates that 65 lives will be saved per 1,000 patients if treatment is administered within the first hour of symptom onset, and 131 lives will be saved per 1,000 patients treated if fibrinolytic therapy is delivered within the first three hours (O’Connor et al., 2010).

The total ischemic time—that is, the time from onset of STEMI symptoms to the initiation of some form of reperfusion therapy—is the principal determinant of health outcomes for patients with an AMI, so timely care is essential to minimize disease morbidity and mortality. Primary PCI is the preferred treatment approach, with guidelines recommending initiation of PCI within 120 minutes from first medical contact (O’Gara et al., 2013). In situations where it is unlikely or impossible for a patient to receive primary PCI within the 120-minute timeframe, fibrinolytic therapy may be used for reperfusion and should be rapidly administered to reduce mortality and minimize morbidity; guidelines recommend that fibrinolytic therapy administration occur within 30 minutes of hospital arrival; this may also require rapid transfer for PCI (O’Gara et al., 2013).

Implementation of an eCQM addressing appropriateness and effectiveness of care for STEMI patients in the ED has the potential to improve the delivery of care furthering alignment with current clinical practice guidelines, while reducing adverse health outcomes such as mortality, bleeding events, and reinfarction. Use of the proposed eCQM could also reduce burden on facilities currently measured using the chart-abstracted Fibrinolytic Therapy Received within 30 Minutes of ED Arrival (OP-2) measure and broaden the population for which performance scores could be publicly reported.

Clinical Recommendation Statement *See CMS996v3.html

Primary PCI in STEMI:

The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that:

- "Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration."

- "Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from first medical contact."

 

Fibrinolytic Therapy when there is an Anticipated Delay to Performing Primary PCI within 120 Minutes of First Medical Contact:

The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that:

- "In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of first medical contact.”

 

Transfer to a PCI-Capable Hospital after Fibrinolytic Therapy:

The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that:

- Immediate transfer to a PCI-capable hospital for coronary angiography is recommended for suitable patients with STEMI who develop cardiogenic shock or acute severe HF, irrespective of the time delay from MI onset.

- Urgent transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who demonstrate evidence of failed reperfusion or reocclusion after fibrinolytic therapy.

- Transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who have received fibrinolytic therapy even when hemodynamically stable and with clinical evidence of successful reperfusion. Angiography can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.

Primary PCI in STEMI:

The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that:

- "Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration."

- "Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from first medical contact."

 

Fibrinolytic Therapy when there is an Anticipated Delay to Performing Primary PCI within 120 Minutes of First Medical Contact:

The 2013 American College of Cardiology Foundation (ACCF)/American Heart Association(AHA) clinical practice guideline for the management of STEMI recommends that:

- "In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of first medical contact.”

 

Transfer to a PCI-Capable Hospital after Fibrinolytic Therapy:

The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that:

- Immediate transfer to a PCI-capable hospital for coronary angiography is recommended for suitable patients with STEMI who develop cardiogenic shock or acute severe heart failure (HF), irrespective of the time delay from MI onset.

- Urgent transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who demonstrate evidence of failed reperfusion or reocclusion after fibrinolytic therapy.

- Transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who have received fibrinolytic therapy even when hemodynamically stable and with clinical evidence of successful reperfusion. Angiography can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.

Improvement Notation

Improvement noted as an increase in the rate

Improvement noted as an increase in the rate

Improvement noted as an increase in the rate

Definition *See CMS996v3.html

None

None

Guidance

This eCQM is an episode-based measure and should be reported for each instance of an ED encounter during the measurement period for patients with a STEMI.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

This eCQM is an episode-based measure and should be reported for each instance of an ED encounter during the measurement period for patients with a STEMI.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

This eCQM is an episode-based measure and should be reported for each instance of an ED encounter during the measurement period for patients with a STEMI.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

Initial Population

All emergency department encounters for patients 18 years and older at the start of the encounter with a diagnosis of ST-segment elevation myocardial infarction (STEMI) during the measurement period

All emergency department encounters for patients 18 years and older at the start of the encounter with a diagnosis of ST-segment elevation myocardial infarction (STEMI) during an Emergency Department encounter that ends during the measurement period

All emergency department encounters for patients 18 years and older at the start of the encounter with a diagnosis of ST-segment elevation myocardial infarction (STEMI) during an Emergency Department encounter that ends during the measurement period

Denominator

Equals Initial Population

Equals Initial Population

Equals Initial Population

Denominator Exclusions

Patients with the following conditions are excluded from measure denominator:

• Expired in the ED

• Allergic reaction to alteplase, streptokinase, anistreplase, tenecteplase, or reteplase

Within 90 days before start of ED encounter:

• Ischemic stroke

• Significant facial and/or closed head trauma

• Peptic ulcer

• Intracranial or intraspinal surgery

Within 21 days before end of ED encounter:

• Major surgery

Within 24 hours before start of ED encounter and during ED encounter:

• Suspected aortic dissection

• Severe neurologic impairment

• Mechanical circulatory assist device placement, including: aortic balloon pump, biventricular assist device, intra-aortic balloon, intra-aortic balloon counterpulsation, intra-aortic counterpulsation balloon pump, left ventricular device, percutaneous ventricular assist device, or ventricular assist device

• Intubation, including endotracheal intubation, mechanical ventilation, nasotracheal intubation, or orotracheal intubation

• Cardiopulmonary arrest, including: cardiac arrest, CPR, defibrillation, respiratory arrest, or ventricular fibrillation (V-fib), ventricular tachycardia (VT), or pulseless electrical activity (PEA); or, traumatic or prolonged (>10 minutes) CPR

At the start of ED encounter:

• Bleeding or bleeding diathesis (excluding menses)

• Known malignant intracranial neoplasm (primary or metastatic)

• Known structural cerebral vascular lesion (e.g., AVM)

• Advanced dementia

• Pregnancy

• Active oral anticoagulant therapy

Patients with the following conditions are excluded from measure denominator:

During ED encounter:

- Allergic reaction to alteplase, streptokinase, anistreplase, tenecteplase, or reteplase

At the start of ED encounter:

- Bleeding or bleeding diathesis (excluding menses)

- Known malignant intracranial neoplasm (primary or metastatic)

- Known structural cerebral vascular lesion (e.g., arteriovenous malformation)

- Advanced dementia

- Pregnancy

- Active oral anticoagulant therapy

Within 24 hours before start of ED encounter or during ED encounter:

- Aortic dissection or ruptured aortic aneurysm

- Severe neurologic impairment

- Mechanical circulatory assist device placement, including: aortic balloon pump, biventricular assist device, intra-aortic balloon, intra-aortic balloon counterpulsation, intra-aortic counterpulsation balloon pump, left ventricular device, percutaneous ventricular assist device, or ventricular assist device

- Intubation, including endotracheal intubation, mechanical ventilation, nasotracheal intubation, or orotracheal intubation

- Cardiopulmonary arrest, including: cardiac arrest, CPR, defibrillation, respiratory arrest, or ventricular fibrillation (V-fib), ventricular tachycardia (VT), or pulseless electrical activity (PEA); or, traumatic or prolonged (>10 minutes) CPR

Within 21 days before start of or starts during ED encounter:

- Major surgery

Within 90 days before start of or at start of ED encounter:

- Ischemic stroke

- Significant facial and/or closed head trauma

- Peptic ulcer

Within 90 days before start of ED encounter:

- Intracranial or intraspinal surgery

Expired in the ED

Patients with the following conditions are excluded from measure denominator:

At some point during ED encounter:

- Allergic reaction to alteplase, streptokinase, anistreplase, tenecteplase, or reteplase

Starts before the start of ED encounter and does not end before ED encounter:

- Bleeding or bleeding diathesis (excluding menses)

- Known malignant intracranial neoplasm (primary or metastatic)

- Known structural cerebral vascular lesion (e.g., arteriovenous malformation)

- Advanced dementia

- Pregnancy

- Diagnosis of allergy to thrombolytics

At the start of ED encounter, or most recent dose within 90 days or less of ED encounter:

-Active oral anticoagulant therapy

Occurs 24 hours or less before start of ED encounter or during ED encounter:

- Aortic dissection or ruptured aortic aneurysm

- Severe neurologic impairment

- Mechanical circulatory assist device placement, including: aortic balloon pump, biventricular assist device, intra-aortic balloon, intra-aortic balloon counterpulsation, intra-aortic counterpulsation balloon pump, left ventricular device, percutaneous ventricular assist device, or ventricular assist device

- Intubation, including endotracheal intubation, mechanical ventilation, nasotracheal intubation, or orotracheal intubation

- Cardiopulmonary arrest, including: cardiac arrest, cardiopulmonary resuscitation (CPR), defibrillation, respiratory arrest, or ventricular fibrillation (V-fib), ventricular tachycardia (VT), or pulseless electrical activity (PEA); or, traumatic or prolonged (>10 minutes) CPR

Occurs 21 days or less before start of or starts during ED encounter:

- Major surgery

Occurs 90 days before start of or at start of ED encounter:

- Ischemic stroke

- Significant facial and/or closed head trauma

- Peptic ulcer

Occurs 90 days or less before start of ED encounter:

- Intracranial or intraspinal surgery

With a discharge disposition of patient expired in the ED

Numerator

Emergency department encounters with a diagnosis of STEMI:

- where time from ED arrival to fibrinolysis is 30 minutes or fewer;

OR

- where PCI is performed within 90 minutes of arrival for non-transfer patients;

OR

- where the patient is transferred within 45 minutes of ED arrival.

Emergency department encounters with a diagnosis of STEMI:

- where time from ED arrival to fibrinolysis is 30 minutes or fewer;

OR

- where PCI is performed within 90 minutes of arrival for non-transfer patients;

OR

- where the patient is transferred within 45 minutes of ED arrival

Emergency department encounters with a diagnosis of STEMI:

- where time from ED arrival to fibrinolysis is 30 minutes or fewer;

OR

- where PCI is performed within 90 minutes of arrival;

OR

- where the patient is transferred within 45 minutes of ED arrival

Numerator Exclusions

Not Applicable

Not Applicable

Not Applicable

Denominator Exceptions

None

None

Emergency department encounters where the patient received fibrinolytic therapy at another facility within 24 hours.

Telehealth Eligible No No No
Next Version No Version Available
Previous Version No Version Available
Specifications

There are known issues on CMS996v3. See issues EKI-24 and EKI-26 on the ONC eCQM Known Issues Dashboard for details.

Last Updated: Jun 03, 2024