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

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

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 2004-2021 International Health Terminology Standards Development Organisation. All rights reserved.

LOINC(R) copyright 2004-2021 Regenstrief Institute, Inc.

These performance specifications are not clinical guidelines and 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].

None

None

None

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

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):311-22.'

Reference Type: CITATION

Reference Text: '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.'

Reference Type: CITATION

Reference Text: '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.'

Reference Type: CITATION

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

None

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.

TBD

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

Equals Initial Population

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

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.

Not Applicable

None

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