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

The percentage of emergency department (ED) patients with a diagnosis of ST-segment elevation myocardial infarction (STEMI) who 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. The measure is intended for use at the facility level in a CMS accountability program, through which it may be publicly reported.

Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets.
CPT® contained in the measure specifications is copyright 2004–2018 American Medical Association. LOINC® copyright 2004–2018 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms® (SNOMED CT®) copyright 2004–2018 International Health Terminology Standards Development Organisation. ICD-10 copyright 2018 World Health Organization. All Rights Reserved.

This performance measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. The measure and specifications are provided without warranty.

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Studies have shown that delays in the treatment of 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.

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.

Improvement noted as an increase in the rate

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):311-22. 

O’Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, Menon V, O’Neil BJ, Travers AH, Yannapoulos D. (2010) Part 10: Acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 122(suppl 3): S787-S817. DOI: 10.1161/CIRCULATIONAHA.110.971028.

O'Gara P, Kushner F, Ascheim D, Casey D, Chung M, de Lemos J, Ettinger S, Fang J, Fesmire F, Franklin B, Granger C, Krumholz H, Linderbaum J, Morrow D, Newby L, Ornato J, Ou N, Radford M, Tamis-Holland J, Tommaso C, Tracy C, Woo Y, Zhao D, Anderson J, Jacobs A, Halperin J, Albert N, Brindis R, Creager M, DeMets D, Guyton R, Hochman J, Kovacs R, Kushner F, Ohman E, Stevenson W, Yancy C. (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. 

Sohlpour A, Yusuf SW. (2014). Fibrinolytic therapy in patients with ST-elevation myocardial infarction. Expert Rev. Cardiovasc. Early online, 1-15.

Use of this measure could potentially improve the delivery of appropriate care (defined as fibrinolytic therapy within 30 minutes of ED arrival, PCI within 90 minutes of ED arrival, or transfer within 45 minutes of ED arrival) for patients presenting with a STEMI to the ED with a disproportionate impact on rural communities; subsequently, implementation could lead to improved health outcomes and decreased costs associated with these improved outcomes.

This measure calculates the percentage of ED patients with a STEMI diagnosis who received appropriate treatment (PCI, fibrinolytic therapy, or transfer). The measure is calculated as follows:
1.	System check E/M Code; if E/M code represents care provided in the ED, proceed 
2.	Calculate Patient Age (Outpatient Encounter Date - Birthdate)
3.	Patient Age >= 18, proceed
4.	System check ICD-10-CM Principal Diagnosis Code;
5.	Apply denominator exclusions to remove patients excluded from the measure denominator; all remaining cases are equal to the denominator count, proceed
6.	System check Fibrinolytic Administration; if “Yes,” proceed; if no
7.	System check PCI Received; if “Yes,” proceed; if no
8.	System check Transferred for PCI; if “Yes,” proceed; 
9.	System check Fibrinolytic Administration Date and Time; if a Non-Unable to Determine (UTD) value, proceed
10.	System check Arrival Time; if a Non-UTD value, proceed
11.	System calculates Time to Fibrinolysis (Fibrinolytic Administration Time minus Arrival Time)
12.	System check Time to Fibrinolysis; if >= 0 min and <= 30 min, include in the numerator. If > 30 min and <=360 min or missing, proceed
13.	System check PCI Received, check PCI Date; if a Non-UTD value, proceed
14.	System check PCI Procedure Time; if a Non-UTD value, proceed
15.	System check Arrival Time; if a Non-UTD value, proceed
16.	System calculate Time to PCI (PCI Procedure Time minus Arrival Time)
17.	System check Time to PCI; if >=0 min and <=90 min, record as the numerator; if >90 minutes and <=360 min or missing, proceed 
18.	System check Transferred for PCI, check Transfer for PCI Date; if a Non-UTD value, proceed
19.	System check Transfer for PCI Time; if a Non-UTD value, proceed
20.	System check Arrival Time; if a Non-UTD value, proceed
21.	System calculate Time to Transfer for PCI; if >=0 min and <=45 min, include in the numerator.
22.	Measure = aggregated numerator counts / aggregated denominator counts [The value should be recorded as a percentage]

ED patients 18 years of age and older with a diagnosis of ST-segment elevation myocardial infarction (STEMI) who should have received appropriate treatment for STEMI.

Equals Initial Population

Patients with the following conditions active at the time of the ED encounter are excluded from measure denominator:
•	Mortality in the ED
•	Bleeding or bleeding diathesis (excluding menses)
•	Intracranial or intraspinal surgery
•	Ischemic stroke 
•	Known malignant intracranial neoplasm (primary or metastatic)
•	Known structural cerebral vascular lesion (e.g., AVM)
•	Significant facial and/or closed head trauma
•	Suspected aortic dissection
•	Peptic ulcer
•	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
•	Allergic reaction to streptokinase/anistreplase
•	Intubation, including endotracheal intubation, mechanical ventilation, nasotracheal intubation, or orotracheal intubation
•	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
•	Oral anticoagulant therapy 
•	Advanced dementia
•	Pregnancy
•	Internal bleeding
•	Major surgery
•	Severe neurologic impairment (e.g., based on Glasgow coma scale or as indicated by the patient receiving therapeutic hypothermia in the ED)

ED STEMI patients whose time from ED arrival to fibrinolysis is 30 minutes or fewer; OR non-transfer ED STEMI patients who received PCI within 90 minutes of arrival; OR, ED STEMI patients who were transferred  within 45 minutes of ED arrival.

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For every patient evaluated by this measure also identify facility ID, race, ethnicity and gender.