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

Compare Versions of: "Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED)"

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Measure Information 2023 Reporting Period 2024 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)
CMS eCQM ID CMS996v3 CMS996v4
Short Name OP-40 (STEMI)

OP-40 (STEMI)
CBE ID 3613e 3613e
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
Definition *See CMS996v3.html

None
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
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
Numerator Exclusions

Not Applicable

Not Applicable
Denominator

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
Denominator Exceptions

None

None
Measure Steward Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS)
Measure Scoring Proportion measure Proportion measure
Measure Type Process measure Process measure
Improvement Notation

Improvement noted as an increase in the rate

Improvement noted as an increase in the rate
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.
Telehealth Eligible No No
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.
Stratification *See CMS996v3.html

None
Risk Adjustment *See CMS996v3.html

None
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.
Notes

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

There are known issues on CMS996v4. See issues EKI-25 and EKI-26 on the ONC eCQM Known Issues Dashboard for details.
Next Version
CMS996v4
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Previous Version No Version Available
CMS996v3
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Attachment Size
CMS996v4.html 89.64 KB
CMS996v4.zip 85.98 KB
CMS996v4-TRN.xlsx 25.16 KB
CMS996v4-eCQMFlow.pdf 294.42 KB

There are known issues on CMS996v4. See issues EKI-25 and EKI-26 on the ONC eCQM Known Issues Dashboard for details.

Data Element Repository
Data Elements contained within CMS996v4
Value Sets
Value Sets to be used with CMS996v4
eCQM Jira Issue Tracker
Tickets for CMS996v4
*Note there may be more tickets in the eCQM Tracker - ONC Project Tracking System (Jira) for this measure. Only tickets tagged with their associated CMS measure ID appear.
Use the eCQM Tracker to open new issues regarding eCQM implementation and the CMS Hybrid Measures Tracker to log issues regarding hybrid measure implementation. Log in required.
CMS996v4-TRN.xlsx

Header

  • Updated grammar, wording, and/or formatting to improve readability and consistency.

    Measure Section: Description

    Source of Change: Annual Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated description of Initial Population timing to align with measure logic and intent.

    Measure Section: Initial Population

    Source of Change: Test Case Review

  • Updated the Initial Population language to indicate the Emergency Department visits that end during the measurement period are captured in this measure.

    Measure Section: Initial Population

    Source of Change: ONC Project Tracking System (JIRA): CQM-5380

  • Updated timing of major surgical procedure denominator exclusion to '21 days or less before start of ED Encounter' to align with other definitions.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated Denominator Exclusion to clarify aortic dissection or ruptured aortic aneurysm satisfies the exclusion criteria to align with measure intent; suspected aortic dissection is not a valid denominator exclusion.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated Denominator Exclusion to clarify the diagnosis of ischemic stroke, significant facial and/or closed head trauma, and peptic ulcer may start within 90 days before the start of the ED encounter or at the start of the ED encounter to better align with measure intent.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (JIRA): CQM-5803

  • Added timing to denominator exclusion to align with measure logic to add 'during ED encounter' for allergic reaction to Thrombolytics.

    Measure Section: Denominator Exclusions

    Source of Change: Test Case Review

  • Revised the order of denominator exclusions in the measure header and logic for readability and listed the exclusions in the header from earliest to latest.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

Logic

  • Updated timing of the 'Emergency Department Evaluation and Management Visti' to require the end of the ED visit occur during the measurement period.

    Measure Section: Denominator

    Source of Change: ONC Project Tracking System (JIRA): CQM-5380

  • Updated Denominator Exclusion to clarify the diagnosis of ischemic stroke, significant facial and/or closed head trauma, and peptic ulcer may start within 90 days before the start of the ED encounter or at the start of the ED encounter to better align with measure intent.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (JIRA): CQM-5803

  • Updated logic to exclude patients who have taken oral anticoagulants before the start of ED encounter.

    Measure Section: Denominator Exclusions

    Source of Change: Test Case Review

  • Updated timing of major surgical procedure denominator exclusion to '21 days or less before start of ED Encounter' to align with other definitions.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

    Measure Section: Definitions

    Source of Change: Standards/Technical Update

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set (2.16.840.1.113883.3.3157.4036): Renamed to Active Bleeding Excluding Menses or Bleeding Diathesis based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Active Bleeding Excluding Menses or Bleeding Diathesis (2.16.840.1.113883.3.3157.4036): Added 4 ICD-10-CM codes (D68.311, D68.312, S06.347A, S06.348A) based on review by technical experts, SMEs, and/or public feedback. Added 8 ICD-10-CM codes (S06.34AA, S06.35AA, S06.36AA, S06.37AA, S06.38AA, S06.4XAA, S06.5XAA, S06.6XAA) based on terminology update.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Acute Peptic Ulcer (2.16.840.1.113883.3.3157.4031): Deleted 1 ICD-10-CM code (K27.9) based on review by technical experts, SMEs, and/or public feedback. Deleted 16 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set (2.16.840.1.113883.3.3157.4031): Renamed to Acute Peptic Ulcer based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Oral Anticoagulant Medications (2.16.840.1.113883.3.3157.4045): Added 2 RxNorm codes (1992427, 2059015) based on review by technical experts, SMEs, and/or public feedback. Added 7 RxNorm codes (2588062, 2590616, 2590620, 2590623, 2590627, 2590631, 2590635) based on terminology update. Deleted 83 RxNorm codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Aortic Dissection or Ruptured Aortic Aneurysm (2.16.840.1.113883.3.3157.4028): Added 7 ICD-10-CM codes (I71.10, I71.11, I71.12, I71.13, I71.50, I71.51, I71.52) based on terminology update. Deleted 2 ICD-10-CM codes (I71.1, I71.5) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set (2.16.840.1.113883.3.3157.4028): Renamed to Aortic Dissection or Ruptured Aortic Aneurysm based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Cardiopulmonary Arrest (2.16.840.1.113883.3.3157.4048): Added 3 ICD-10-CM codes (I47.20, I47.21, I47.29) based on terminology update. Deleted 1 ICD-10-CM code (I47.2) based on terminology update. Deleted 1 SNOMED CT code (429046004) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Cerebral Vascular Lesion (2.16.840.1.113883.3.3157.4025): Added 151 ICD-10-CM codes based on review by technical experts, SMEs, and/or public feedback. Added 265 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 3 SNOMED CT codes (230718007, 24551003, 733927008) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Dementia and Related Intracranial Pathologies (2.16.840.1.113883.3.3157.4043): Added 69 ICD-10-CM codes based on terminology update. Deleted 1 SNOMED CT code (230283005) based on terminology update. Deleted 1 SNOMED CT code (161465002) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set (2.16.840.1.113883.3.3157.4043): Renamed to Dementia and Related Intracranial Pathologies based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set (2.16.840.1.113883.3.464.1003.101.12.1010): Renamed to Emergency Department Evaluation and Management Visit based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Fibrinolytic Therapy (2.16.840.1.113883.3.3157.4019): Deleted 54 RxNorm codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set (2.16.840.1.113883.3.3157.4052): Renamed to Insertion or Replacement of Mechanical Circulatory Assist Device based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Insertion or Replacement of Mechanical Circulatory Assist Device (2.16.840.1.113883.3.3157.4052): Added 5 CPT codes (33981, 33993, 33982, 33983, 33995) based on review by technical experts, SMEs, and/or public feedback. Deleted 4 CPT codes (0451T, 0452T, 0453T, 0454T) based on terminology update. Deleted 2 CPT codes (1006349, 1029971) based on review by technical experts, SMEs, and/or public feedback. Deleted 14 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Intracranial or Intraspinal surgery (2.16.840.1.113762.1.4.1170.2): Added 1 SNOMED CT code (1201979001) based on terminology update. Deleted 3 SNOMED CT codes (171446006, 244238001, 82443007) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Major Surgical Procedure (2.16.840.1.113883.3.3157.4056): Added 79 SNOMED CT codes based on terminology update. Deleted 5579 SNOMED CT codes based on terminology update. Deleted 18 ICD-10-PCS codes based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Malignant Intracranial Neoplasm Group (2.16.840.1.113762.1.4.1170.3): Deleted 39 ICD-10-CM codes based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (189162003) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set (2.16.840.1.113883.3.3157.4045): Renamed to Oral Anticoagulant Medications based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set (2.16.840.1.113762.1.4.1170.6): Renamed to Thrombolytics Adverse Event based on recommended value set naming conventions.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Thrombolytics Adverse Event (2.16.840.1.113762.1.4.1170.6): Added 1 SNOMED CT code (218568007) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Mar 04, 2024