eCQM Title

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

CMS ID

996

eCQM Version Number

6.3.000

CBE Number

3613e

GUID

fb8caab1-dc9e-4a95-b14f-4f5dee7c6587

Measurement Period

January 1, 2026 through December 31, 2026

Measure Steward

Centers for Medicare & Medicaid Services (CMS)

Measure Developer

Acumen, LLC

Endorsed By

CMS Consensus Based Entity

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 discharge to an acute care facility within 45 minutes of ED arrival

Limited proprietary coding is contained in these specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets.

This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation. All rights reserved.

LOINC(R) copyright 2004-2024 Regenstrief Institute, Inc.

CPT(R) contained in the measure specifications is copyright 2004-2024 American Medical Association.

ICD-10 is copyright 2024 World Health Organization. All Rights Reserved.

Disclaimer

These performance specifications are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Measure Scoring

Proportion

Measure Type

Process

Stratification

None

Risk Adjustment

None

Rate Aggregation

None

Rationale

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 (Solhpour & Yusuf, 2013; 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 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

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

Increased score indicates improvement

Reference

Reference Type: Citation

Reference Text: 'Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. (1994). Indications for fibrinolytic therapy in suspected acute myocardial infarction: Collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. The Lancet, 343(8893):311-322. https://doi.org/10.1016/S0140-6736(94)91161-4'

Reference

Reference Type: Citation

Reference Text: 'O'Gara, P. T., Kushner, F. G., Ascheim, D. D., Casey, D. E., Chung, M. K., de Lemos, J. A., . . . Zhao, D. X. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 127(4): e362-425. https://doi.org/10.1161/CIR.0b013e3182742cf6'

Reference

Reference Type: Citation

Reference Text: 'O’Connor, R. E., Brady, W., Brooks, S. C., Diercks, D., Egan, J., Ghaemmaghami, C., . . . Yannapoulos, D. (2010). Part 10: Acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, s(suppl 3): S787-S817. DOI: 10.1161/circulationaha.110.971028'

Reference

Reference Type: Citation

Reference Text: 'Solhpour, A., & Yusuf, S. W. (2013). Fibrinolytic therapy in patients with ST-elevation myocardial infarction. Expert Review of Cardiovascular Therapy, 12(2):201–15. https://doi.org/10.1586/14779072.2014.867805'

Definition

None

Guidance

In order to support the best outcomes for patients and align with other guidelines, PCI device deployment time should be used for calculating the “PCI is performed within 90 minutes of ED arrival” numerator criteria and not the start time of the procedure.

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 eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Transmission Format

TBD

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 an Emergency Department encounter that ends during the measurement period

Denominator

Equals Initial Population

Denominator Exclusions

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 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, Angina pectoris with documented spasm, Aneurysm of heart, Ventricular aneurysm due to and following acute myocardial infarction, Takotsubo cardiomyopathy or syndrome
- Severe neurologic impairment
- Mechanical circulatory assist device placement or removal, 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 within 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

With a discharge disposition of left against medical advice

With documentation of hospice services in the 6 months within start of ED encounter, or active hospice status at start of ED encounter

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; 
OR
- where the patient is discharged to an acute care facility within 45 minutes of ED arrival

Numerator Exclusions

None

Denominator Exceptions

Emergency department encounters where the patient received fibrinolytic therapy at another facility within 24 hours.
Emergency department encounters with a documented reason for not administering fibrinolytic therapy within 30 minutes of ED arrival.
Emergency department encounters with a documented reason for not performing a PCI within 90 minutes of ED arrival.

Supplemental Data Elements

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Population Criteria
Definitions
Functions
Terminology
Data Criteria (QDM Data Elements)
Supplemental Data Elements
Risk Adjustment Variables

Population Criteria

Initial Population

  "ED Encounter With STEMI Diagnosis" EDwSTEMI

- Denominator
  - "Initial Population"

Denominator Exclusions

  "Allergy Or Intolerance To Thrombolytic Medications Overlaps ED Encounter"
    union "Adverse Effect To Thrombolytic Medications Before End Of ED Encounter"
    union "Active Exclusion Diagnosis At Start Of ED Encounter"
    union "Active Use Of Anticoagulants"
    union "Exclusion Diagnosis During ED Encounter Or Within 24 Hours Of ED Encounter Start"
    union "Major Surgical Procedure 21 Days Or Less Before Start Of Or Starts During ED Encounter"
    union "Intubation Or Mechanical Circulatory Assist Device Placement Or Removal Procedure During ED Encounter Or Within 24 Hours Of ED Encounter Start"
    union "Active Exclusion Diagnosis Within 90 Days Before Or At The Start Of ED Encounter"
    union "Intracranial Or Intraspinal Procedure 90 Days Or Less Before Start Of ED Encounter"
    union "ED Encounter With Discharge Disposition As Patient Expired"
    union "ED Encounter With Discharge Disposition As Left Against Medical Advice" 
    union "ED Encounter With Hospice Services"

Numerator

  ( "Fibrinolytic Therapy Administration Within 30 Minutes Of Arrival"
      union "PCI Within 90 Minutes Of Arrival"
      union "ED Departure With Discharge To Acute Care Facility Within 45 Minutes Of Arrival"
  )

- Numerator Exclusions
  - None

Denominator Exceptions

  "Received TPA In Another Facility Within 24 hours Prior To Admission"
    union "ED Encounter With A Documented Reason For No PCI Performed Within 90 Minutes Of ED Arrival"
    union "ED Encounter With A Documented Reason For Not Administering Fibrinolytic Therapy Within 30 Minutes Of ED Arrival"

- Stratification
  - None

Definitions

Active Exclusion Diagnosis At Start Of ED Encounter

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with ( ["Diagnosis": "Active Bleeding or Bleeding Diathesis, Excluding Menses"]
      union ["Diagnosis": "Malignant Intracranial Neoplasm Group"]
      union ["Diagnosis": "Cerebral Vascular Lesion"]
      union ["Diagnosis": "Dementia and Related Intracranial Pathologies"]
      union ["Diagnosis": "Pregnant State"]
      union ["Diagnosis": "Allergy to thrombolytics"] ) ActiveExclusionDx
      such that ActiveExclusionDx.prevalencePeriod overlaps before EDwSTEMI.relevantPeriod

Active Exclusion Diagnosis Within 90 Days Before Or At The Start Of ED Encounter

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with ( ["Diagnosis": "Ischemic Stroke"]
      union ["Diagnosis": "Closed Head and Facial Trauma"]
      union ["Diagnosis": "Acute Peptic Ulcer"] ) DxExclusion
      such that ( DxExclusion.prevalencePeriod starts during Interval[start of EDwSTEMI.relevantPeriod - 90 days, start of EDwSTEMI.relevantPeriod])

Active Long Term Use Of Anticoagulants

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with ["Diagnosis": "Long term (current) use of anticoagulants"] LongTermAnticoagulant
      such that ( Global."HasStart" ( LongTermAnticoagulant.prevalencePeriod )
          and LongTermAnticoagulant.prevalencePeriod starts before or on start of EDwSTEMI.relevantPeriod
          and LongTermAnticoagulant.prevalencePeriod ends on or after start of EDwSTEMI.relevantPeriod
       )

Active Oral Anticoagulant Medication At The Start Of ED Encounter

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with ["Medication, Active": "Oral Anticoagulant Medications"] OralAnticoagulant
      such that ( Global."HasStart" ( OralAnticoagulant.relevantPeriod )
          and OralAnticoagulant.relevantPeriod starts before or on start of EDwSTEMI.relevantPeriod
          and OralAnticoagulant.relevantPeriod ends on or after start of EDwSTEMI.relevantPeriod
      )
        or ( OralAnticoagulant.relevantDatetime 90 days or less before or on EDwSTEMI.relevantPeriod )

Active Use Of Anticoagulants

  "Active Oral Anticoagulant Medication At The Start Of ED Encounter"
  union "Active Long Term Use Of Anticoagulants"

Adverse Effect To Thrombolytic Medications Before End Of ED Encounter

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with ["Adverse Event": "Thrombolytic medications"] ThrombolyticAdverseEvent
      such that ThrombolyticAdverseEvent.type in "Thrombolytics Adverse Event"
        and ThrombolyticAdverseEvent.relevantDatetime before end of EDwSTEMI.relevantPeriod

Allergy Or Intolerance To Thrombolytic Medications Overlaps ED Encounter

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with ["Allergy/Intolerance": "Thrombolytic medications"] ThrombolyticAllergy
      such that ThrombolyticAllergy.prevalencePeriod overlaps EDwSTEMI.relevantPeriod

Denominator
- - "Initial Population"

Denominator Exceptions

  "Received TPA In Another Facility Within 24 hours Prior To Admission"
    union "ED Encounter With A Documented Reason For No PCI Performed Within 90 Minutes Of ED Arrival"
    union "ED Encounter With A Documented Reason For Not Administering Fibrinolytic Therapy Within 30 Minutes Of ED Arrival"

Denominator Exclusions

  "Allergy Or Intolerance To Thrombolytic Medications Overlaps ED Encounter"
    union "Adverse Effect To Thrombolytic Medications Before End Of ED Encounter"
    union "Active Exclusion Diagnosis At Start Of ED Encounter"
    union "Active Use Of Anticoagulants"
    union "Exclusion Diagnosis During ED Encounter Or Within 24 Hours Of ED Encounter Start"
    union "Major Surgical Procedure 21 Days Or Less Before Start Of Or Starts During ED Encounter"
    union "Intubation Or Mechanical Circulatory Assist Device Placement Or Removal Procedure During ED Encounter Or Within 24 Hours Of ED Encounter Start"
    union "Active Exclusion Diagnosis Within 90 Days Before Or At The Start Of ED Encounter"
    union "Intracranial Or Intraspinal Procedure 90 Days Or Less Before Start Of ED Encounter"
    union "ED Encounter With Discharge Disposition As Patient Expired"
    union "ED Encounter With Discharge Disposition As Left Against Medical Advice" 
    union "ED Encounter With Hospice Services"

ED Departure With Discharge To Acute Care Facility Within 45 Minutes Of Arrival

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with ( Global."HospitalDepartureTime" ( EDwSTEMI ) ) Departure
      such that Departure 45 minutes or less after Global."EmergencyDepartmentArrivalTime" ( EDwSTEMI )
        and EDwSTEMI.dischargeDisposition in "Discharge To Acute Care Facility"

ED Encounter During MP

  ["Encounter, Performed": "Emergency Department Evaluation and Management Visit"] EDEncounter
    where (EDEncounter.relevantPeriod ends during day of "Measurement Period" and AgeInYearsAt(date from start of EDEncounter.relevantPeriod) >= 18)

ED Encounter With A Documented Reason For No PCI Performed Within 90 Minutes Of ED Arrival

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with (["Procedure, Not Performed": "Percutaneous Coronary Intervention"] NoPCI
          where (NoPCI.negationRationale in "Patient Refusal" or NoPCI.negationRationale in "Procedure Not Indicated/Contraindicated")) PCIRefused
    such that PCIRefused.authorDatetime during EDwSTEMI.relevantPeriod

ED Encounter With A Documented Reason For Not Administering Fibrinolytic Therapy Within 30 Minutes Of ED Arrival

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with (["Medication, Not Administered": "Fibrinolytic Therapy"] NoFibrinolytic
          where (NoFibrinolytic.negationRationale in "Patient Refusal" or NoFibrinolytic.negationRationale in "Drug Intervention Not Indicated/Contraindicated")) FibrinolyticRefused
    such that FibrinolyticRefused.authorDatetime during EDwSTEMI.relevantPeriod

ED Encounter With Discharge Disposition As Left Against Medical Advice

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    where EDwSTEMI.dischargeDisposition in "Left Against Medical Advice"

ED Encounter With Discharge Disposition As Patient Expired

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    where EDwSTEMI.dischargeDisposition in "Patient Expired"

ED Encounter With Hospice Services

  from "ED Encounter With STEMI Diagnosis" EDwSTEMI
  let SixMonthsBeforeToEndOfSTEMI: Interval[start of EDwSTEMI.relevantPeriod - 6 months, end of EDwSTEMI.relevantPeriod]
  where (
    exists ( ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
      where ( InpatientEncounter.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
            or InpatientEncounter.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)")
            and ( Global."HasStart" ( InpatientEncounter.relevantPeriod )
                and InpatientEncounter.relevantPeriod overlaps day of SixMonthsBeforeToEndOfSTEMI
            )
    )     
    or exists ( ["Encounter, Performed": "Hospice Encounter"] HospiceEncounter
        where ( Global."HasStart" ( HospiceEncounter.relevantPeriod )
          and HospiceEncounter.relevantPeriod overlaps day of SixMonthsBeforeToEndOfSTEMI
        ) 
    )
    or exists ( ["Assessment, Performed": "Hospice care [Minimum Data Set]"] HospiceAssessment
        where (HospiceAssessment.result ~ "Yes (qualifier value)"
            and (HospiceAssessment.relevantDatetime 6 months or less before start of EDwSTEMI.relevantPeriod 
                or (Global."HasStart" ( HospiceAssessment.relevantPeriod )
                    and HospiceAssessment.relevantPeriod overlaps day of SixMonthsBeforeToEndOfSTEMI
                )
            )
        ) 
    ) 
    or exists ( ["Intervention, Order": "Hospice Care Ambulatory"] HospiceOrder
        where (HospiceOrder.authorDatetime 6 months or less before start of EDwSTEMI.relevantPeriod  )
    )
    or exists ( ["Intervention, Performed": "Hospice Care Ambulatory"] HospicePerformed
        where (HospicePerformed.relevantDatetime 6 months or less before start of EDwSTEMI.relevantPeriod or 
               (Global."HasStart" ( HospicePerformed.relevantPeriod )
                  and HospicePerformed.relevantPeriod overlaps day of SixMonthsBeforeToEndOfSTEMI
                )
        )
    ) 
    or exists ( ["Diagnosis": "Hospice Diagnosis"] HospiceCareDiagnosis
        where ( HospiceCareDiagnosis.prevalencePeriod ends on or after start of EDwSTEMI.relevantPeriod )
    )
  )

ED Encounter With STEMI Diagnosis

  "ED Encounter During MP" EDEncounterinMP
    where (exists (["Diagnosis": "STEMI"] DxSTEMI
      where DxSTEMI.prevalencePeriod starts during EDEncounterinMP.relevantPeriod))
    or (exists( EDEncounterinMP.diagnoses EncounterDiagnosis
      where EncounterDiagnosis.code in "STEMI" ))

Exclusion Diagnosis During ED Encounter Or Within 24 Hours Of ED Encounter Start

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with ( ["Diagnosis": "Aortic Dissection or Ruptured Aortic Aneurysm"]
      union ["Diagnosis": "Neurologic impairment"]
      union ["Diagnosis": "Cardiopulmonary Emergency"] 
      union ["Diagnosis": "Angina pectoris with documented spasm"]
      union ["Diagnosis": "Ventricular aneurysm due to and following acute myocardial infarction (disorder)"]
      union ["Diagnosis": "Aneurysm of heart"]
      union ["Diagnosis": "Takotsubo cardiomyopathy (disorder)"]
      union ["Diagnosis": "Takotsubo syndrome"]      
      ) ExclusionDx
      such that ( ExclusionDx.prevalencePeriod starts during EDwSTEMI.relevantPeriod
          or ExclusionDx.prevalencePeriod starts 24 hours or less before start of EDwSTEMI.relevantPeriod
      )

Fibrinolytic Therapy Administration Within 30 Minutes Of Arrival

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with ["Medication, Administered": "Fibrinolytic Therapy"] Fibrinolytic
      such that Global."NormalizeInterval" ( Fibrinolytic.relevantDatetime, Fibrinolytic.relevantPeriod ) starts 30 minutes or less after Global."EmergencyDepartmentArrivalTime" ( EDwSTEMI )

Initial Population

  "ED Encounter With STEMI Diagnosis" EDwSTEMI

Intracranial Or Intraspinal Procedure 90 Days Or Less Before Start Of ED Encounter

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with ["Procedure, Performed": "Intracranial or Intraspinal surgery"] CranialorSpinalSurgery
      such that Global."NormalizeInterval" ( CranialorSpinalSurgery.relevantDatetime, CranialorSpinalSurgery.relevantPeriod ) starts 90 days or less before start of EDwSTEMI.relevantPeriod

Intubation Or Mechanical Circulatory Assist Device Placement Or Removal Procedure During ED Encounter Or Within 24 Hours Of ED Encounter Start

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with ( ["Procedure, Performed": "Endotracheal Intubation"]
      union ["Procedure, Performed": "Mechanical Circulatory Assist Device"] ) AirwayProcedure
      such that ( Global."NormalizeInterval" ( AirwayProcedure.relevantDatetime, AirwayProcedure.relevantPeriod ) starts during EDwSTEMI.relevantPeriod
          or Global."NormalizeInterval" ( AirwayProcedure.relevantDatetime, AirwayProcedure.relevantPeriod ) starts 24 hours or less before start of EDwSTEMI.relevantPeriod
      )

Major Surgical Procedure 21 Days Or Less Before Start Of Or Starts During ED Encounter

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with ["Procedure, Performed": "Major Surgical Procedure"] MajorSurgery
      such that Global."NormalizeInterval" ( MajorSurgery.relevantDatetime, MajorSurgery.relevantPeriod ) starts 21 days or less before start of EDwSTEMI.relevantPeriod
      or Global."NormalizeInterval" ( MajorSurgery.relevantDatetime, MajorSurgery.relevantPeriod ) starts during EDwSTEMI.relevantPeriod

Numerator

  ( "Fibrinolytic Therapy Administration Within 30 Minutes Of Arrival"
      union "PCI Within 90 Minutes Of Arrival"
      union "ED Departure With Discharge To Acute Care Facility Within 45 Minutes Of Arrival"
  )

PCI Within 90 Minutes Of Arrival

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with ["Procedure, Performed": "Percutaneous Coronary Intervention"] PCI
      such that Global."NormalizeInterval" ( PCI.relevantDatetime, PCI.relevantPeriod ) starts 90 minutes or less after Global."EmergencyDepartmentArrivalTime" ( EDwSTEMI )

Received TPA In Another Facility Within 24 hours Prior To Admission

  "ED Encounter With STEMI Diagnosis" EDwSTEMI
    with ( ["Diagnosis": "Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility"] ) TPA
      such that TPA.prevalencePeriod starts during EDwSTEMI.relevantPeriod

SDE Ethnicity

  ["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

  ["Patient Characteristic Payer": "Payer Type"]

SDE Race

  ["Patient Characteristic Race": "Race"]

SDE Sex

  ["Patient Characteristic Sex": "Federal Administrative Sex"]

Functions

Global.EmergencyDepartmentArrivalTime(Encounter "Encounter, Performed")

  start of First(("HospitalizationLocations"(Encounter))HospitalLocation
  		where HospitalLocation.code in "Emergency Department Visit"
  		sort by start of locationPeriod
  ).locationPeriod

Global.HasStart(period Interval<DateTime>)

  not ( start of period is null
      or start of period = minimum DateTime
  )

Global.HospitalDepartureTime(Encounter "Encounter, Performed")

  end of Last(("HospitalizationLocations"(Encounter))HospitalLocation
  		sort by start of locationPeriod
  ).locationPeriod

Global.HospitalizationLocations(Encounter "Encounter, Performed")

  Encounter Visit
  	let EDVisit: Last(["Encounter, Performed": "Emergency Department Visit"] LastED
  			where LastED.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod
  			sort by 
  			end of relevantPeriod
  	)
  	return if EDVisit is null then Visit.facilityLocations 
  		else flatten { EDVisit.facilityLocations, Visit.facilityLocations }

Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

  if pointInTime is not null then Interval[pointInTime, pointInTime]
    else if period is not null then period 
    else null as Interval<DateTime>

Terminology

code "Aneurysm of heart" ("ICD10CM Code (I25.3)")
code "Angina pectoris with documented spasm" ("ICD10CM Code (I20.1)")
code "Discharge to healthcare facility for hospice care (procedure)" ("SNOMEDCT Code (428371000124100)")
code "Discharge to home for hospice care (procedure)" ("SNOMEDCT Code (428361000124107)")
code "Hospice care [Minimum Data Set]" ("LOINC Code (45755-6)")
code "Long term (current) use of anticoagulants" ("ICD10CM Code (Z79.01)")
code "Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility" ("ICD10CM Code (Z92.82)")
code "Takotsubo cardiomyopathy (disorder)" ("SNOMEDCT Code (441541008)")
code "Takotsubo syndrome" ("ICD10CM Code (I51.81)")
code "Ventricular aneurysm due to and following acute myocardial infarction (disorder)" ("SNOMEDCT Code (723858002)")
code "Yes (qualifier value)" ("SNOMEDCT Code (373066001)")
valueset "Active Bleeding or Bleeding Diathesis, Excluding Menses" (2.16.840.1.113883.3.3157.4036)
valueset "Acute Peptic Ulcer" (2.16.840.1.113883.3.3157.4031)
valueset "Allergy to thrombolytics" (2.16.840.1.113762.1.4.1170.5)
valueset "Aortic Dissection or Ruptured Aortic Aneurysm" (2.16.840.1.113883.3.3157.4028)
valueset "Cardiopulmonary Emergency" (2.16.840.1.113883.3.3157.4048)
valueset "Cerebral Vascular Lesion" (2.16.840.1.113883.3.3157.4025)
valueset "Closed Head and Facial Trauma" (2.16.840.1.113883.3.3157.4026)
valueset "Dementia and Related Intracranial Pathologies" (2.16.840.1.113883.3.3157.4043)
valueset "Discharge To Acute Care Facility" (2.16.840.1.113883.3.117.1.7.1.87)
valueset "Drug Intervention Not Indicated/Contraindicated" (2.16.840.1.113762.1.4.1282.1)
valueset "Emergency Department Evaluation and Management Visit" (2.16.840.1.113883.3.464.1003.101.12.1010)
valueset "Emergency Department Visit" (2.16.840.1.113883.3.117.1.7.1.292)
valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
valueset "Endotracheal Intubation" (2.16.840.1.113762.1.4.1045.69)
valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
valueset "Federal Administrative Sex" (2.16.840.1.113762.1.4.1021.121)
valueset "Fibrinolytic Therapy" (2.16.840.1.113883.3.3157.4019)
valueset "Hospice Care Ambulatory" (2.16.840.1.113883.3.526.3.1584)
valueset "Hospice Diagnosis" (2.16.840.1.113883.3.464.1003.1165)
valueset "Hospice Encounter" (2.16.840.1.113883.3.464.1003.1003)
valueset "Intracranial or Intraspinal surgery" (2.16.840.1.113762.1.4.1170.2)
valueset "Ischemic Stroke" (2.16.840.1.113883.3.117.1.7.1.247)
valueset "Left Against Medical Advice" (2.16.840.1.113883.3.117.1.7.1.308)
valueset "Major Surgical Procedure" (2.16.840.1.113883.3.3157.4056)
valueset "Malignant Intracranial Neoplasm Group" (2.16.840.1.113762.1.4.1170.3)
valueset "Mechanical Circulatory Assist Device" (2.16.840.1.113883.3.3157.4052)
valueset "Neurologic impairment" (2.16.840.1.113883.3.464.1003.114.12.1012)
valueset "Oral Anticoagulant Medications" (2.16.840.1.113883.3.3157.4045)
valueset "Patient Expired" (2.16.840.1.113883.3.117.1.7.1.309)
valueset "Patient Refusal" (2.16.840.1.113883.3.117.1.7.1.93)
valueset "Payer Type" (2.16.840.1.114222.4.11.3591)
valueset "Percutaneous Coronary Intervention" (2.16.840.1.113883.3.3157.2000.5)
valueset "Pregnant State" (2.16.840.1.113883.3.3157.4055)
valueset "Procedure Not Indicated/Contraindicated" (2.16.840.1.113762.1.4.1282.2)
valueset "Race" (2.16.840.1.114222.4.11.836)
valueset "STEMI" (2.16.840.1.113883.3.3157.4017)
valueset "Thrombolytic medications" (2.16.840.1.113762.1.4.1170.4)
valueset "Thrombolytics Adverse Event" (2.16.840.1.113762.1.4.1170.6)

Data Criteria (QDM Data Elements)

"Adverse Event: Thrombolytic medications" using "Thrombolytic medications (2.16.840.1.113762.1.4.1170.4)"
"Allergy/Intolerance: Thrombolytic medications" using "Thrombolytic medications (2.16.840.1.113762.1.4.1170.4)"
"Assessment, Performed: Hospice care [Minimum Data Set]" using "Hospice care [Minimum Data Set] (LOINC Code 45755-6)"
"Diagnosis: Active Bleeding or Bleeding Diathesis, Excluding Menses" using "Active Bleeding or Bleeding Diathesis, Excluding Menses (2.16.840.1.113883.3.3157.4036)"
"Diagnosis: Acute Peptic Ulcer" using "Acute Peptic Ulcer (2.16.840.1.113883.3.3157.4031)"
"Diagnosis: Allergy to thrombolytics" using "Allergy to thrombolytics (2.16.840.1.113762.1.4.1170.5)"
"Diagnosis: Aneurysm of heart" using "Aneurysm of heart (ICD10CM Code I25.3)"
"Diagnosis: Angina pectoris with documented spasm" using "Angina pectoris with documented spasm (ICD10CM Code I20.1)"
"Diagnosis: Aortic Dissection or Ruptured Aortic Aneurysm" using "Aortic Dissection or Ruptured Aortic Aneurysm (2.16.840.1.113883.3.3157.4028)"
"Diagnosis: Cardiopulmonary Emergency" using "Cardiopulmonary Emergency (2.16.840.1.113883.3.3157.4048)"
"Diagnosis: Cerebral Vascular Lesion" using "Cerebral Vascular Lesion (2.16.840.1.113883.3.3157.4025)"
"Diagnosis: Closed Head and Facial Trauma" using "Closed Head and Facial Trauma (2.16.840.1.113883.3.3157.4026)"
"Diagnosis: Dementia and Related Intracranial Pathologies" using "Dementia and Related Intracranial Pathologies (2.16.840.1.113883.3.3157.4043)"
"Diagnosis: Hospice Diagnosis" using "Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165)"
"Diagnosis: Ischemic Stroke" using "Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247)"
"Diagnosis: Long term (current) use of anticoagulants" using "Long term (current) use of anticoagulants (ICD10CM Code Z79.01)"
"Diagnosis: Malignant Intracranial Neoplasm Group" using "Malignant Intracranial Neoplasm Group (2.16.840.1.113762.1.4.1170.3)"
"Diagnosis: Neurologic impairment" using "Neurologic impairment (2.16.840.1.113883.3.464.1003.114.12.1012)"
"Diagnosis: Pregnant State" using "Pregnant State (2.16.840.1.113883.3.3157.4055)"
"Diagnosis: Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility" using "Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility (ICD10CM Code Z92.82)"
"Diagnosis: STEMI" using "STEMI (2.16.840.1.113883.3.3157.4017)"
"Diagnosis: Takotsubo cardiomyopathy (disorder)" using "Takotsubo cardiomyopathy (disorder) (SNOMEDCT Code 441541008)"
"Diagnosis: Takotsubo syndrome" using "Takotsubo syndrome (ICD10CM Code I51.81)"
"Diagnosis: Ventricular aneurysm due to and following acute myocardial infarction (disorder)" using "Ventricular aneurysm due to and following acute myocardial infarction (disorder) (SNOMEDCT Code 723858002)"
"Encounter, Performed: Emergency Department Evaluation and Management Visit" using "Emergency Department Evaluation and Management Visit (2.16.840.1.113883.3.464.1003.101.12.1010)"
"Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit (2.16.840.1.113883.3.117.1.7.1.292)"
"Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
"Encounter, Performed: Hospice Encounter" using "Hospice Encounter (2.16.840.1.113883.3.464.1003.1003)"
"Intervention, Order: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
"Intervention, Performed: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
"Medication, Active: Oral Anticoagulant Medications" using "Oral Anticoagulant Medications (2.16.840.1.113883.3.3157.4045)"
"Medication, Administered: Fibrinolytic Therapy" using "Fibrinolytic Therapy (2.16.840.1.113883.3.3157.4019)"
"Medication, Not Administered: Fibrinolytic Therapy" using "Fibrinolytic Therapy (2.16.840.1.113883.3.3157.4019)"
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer Type" using "Payer Type (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: Federal Administrative Sex" using "Federal Administrative Sex (2.16.840.1.113762.1.4.1021.121)"
"Procedure, Not Performed: Percutaneous Coronary Intervention" using "Percutaneous Coronary Intervention (2.16.840.1.113883.3.3157.2000.5)"
"Procedure, Performed: Endotracheal Intubation" using "Endotracheal Intubation (2.16.840.1.113762.1.4.1045.69)"
"Procedure, Performed: Intracranial or Intraspinal surgery" using "Intracranial or Intraspinal surgery (2.16.840.1.113762.1.4.1170.2)"
"Procedure, Performed: Major Surgical Procedure" using "Major Surgical Procedure (2.16.840.1.113883.3.3157.4056)"
"Procedure, Performed: Mechanical Circulatory Assist Device" using "Mechanical Circulatory Assist Device (2.16.840.1.113883.3.3157.4052)"
"Procedure, Performed: Percutaneous Coronary Intervention" using "Percutaneous Coronary Intervention (2.16.840.1.113883.3.3157.2000.5)"

Supplemental Data Elements

SDE Ethnicity

  ["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

  ["Patient Characteristic Payer": "Payer Type"]

SDE Race

  ["Patient Characteristic Race": "Race"]

SDE Sex

  ["Patient Characteristic Sex": "Federal Administrative Sex"]

Risk Adjustment Variables

None

Measure Set