Acute myocardial infarction (AMI) patients with ST-segment elevation on the ECG closest to arrival time receiving primary PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less.

Measure specifications are in the Public Domain.

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This material contains SNOMED Clinical Terms (R) (SNOMED CT(c)) copyright 2004-2010 International Health Terminology Standards Development Organization. All rights reserved.

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The early use of primary angioplasty in patients with ST-segment myocardial infarction (STEMI) results in a significant reduction in mortality and morbidity. The earlier primary coronary intervention is provided, the more effective it is (Brodie, 1998 and DeLuca, 2004). National guidelines recommend the prompt initiation of PCI in patients presenting with ST-elevation myocardial infarction (O'Gara, 2013; Antman and Levine 2011).

National guidelines recommend the prompt initiation of PCI in patients presenting with ST-elevation myocardial infarction

Higher score indicates better quality

Brodie BR, Stuckey TD, Wall TC, Kissling G, Hansen CJ, Muncy DB, et al. Importance of time to reperfusion for 30-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction. J Am Coll Cardiol. 1998;32:1312-9.

DeLuca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation 2004;109(10):1223-1225.

Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, et al. ACC/AHA 2008 performance measures for adults with ST-elevation and non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures for ST-Elevation and Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 –99.

Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44–122.

O’Gara PT, Kushner FG, Ascheim DD, Casey DE, Jr, Chung MK, de Lemos JA, et al. 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. J Am Coll Cardiol 2013;61:485–510.

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Because of QDM limitations to identify the closest event to another event, the denominator will identify the last ECG performed within 1 hour prior to hospital arrival OR the first ECG performed after hospital arrival.

For the denominator data element "Diagnostic Study, Result: Hospital Measures-ECG Impression," EHR implementations will need to develop mechanisms to capture ECG findings to support denominator criteria for this measure. The measure specification indicates allowable findings. The source of the ECG results should be a physician/APN/PA (rather than the ECG machine's computerized results).

Numerator element guidance:
This measure expects a PCI procedure within 90 minutes of hospital arrival.  Those patients receiving PCI procedures greater than 90 minutes after arrival may be excluded from the denominator only if there is a documented reason for a delay or documented occurrence of intubation, cardiopulmonary arrest or mechanical circulatory assist device placement within the first 90 minutes after arrival. Patients receiving PCI procedures greater than 90 minutes after arrival and with no reason provided are not compliant with the numerator criteria and will remain in the denominator.

Denominator and Numerator element guidance:
For the denominator and numerator data element "Occurrence A of Procedure, Performed: Hospital Measures-PCI" and time of start, EHR implementations will need to develop mechanisms to capture the time the balloon was inflated, the time the stent was deployed, or the time a thrombectomy device was used to treat the lesion, whichever is earliest.

Exclusion element guidance: 
The intent for the exclusion for patients who are clinical trial participants was to be limited to patients participating in a clinical trial for acute myocardial infarction (AMI), ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (non-STEMI), heart attack, or acute coronary syndrome (ACS), the same conditions as covered by the measure. However, the value set specifying clinical trial participation is not limited to a specific type of trial.

Transfers from another hospital are excluded since care may have been delivered in the other setting. Transfers from those hospitals are considered exclusions regardless of whether the receiving hospital has the same or different hospital unique identifier as the transferring hospital.  

PCI procedures analyzed in this measure must be primary procedures. Primary includes emergent or urgent PCI procedures and not those described by the physician/APN/PA anywhere in the record as elective, not emergent, not immediate, not primary, not urgent, or secondary.

From a clinical standpoint, Primary PCI is loosely defined as percutaneous coronary intervention performed in the acute setting in patients with ST segment elevation MI which is intended to restore perfusion in the infarct-related artery. In randomized trials and observational studies, this therapy is associated with significant reductions in the risks of adverse events, including death, in selected patients with STEMI.

Exception element guidance: 
Medical or patient reasons for not performing a procedure or giving a medication are categories for valid medical or patient reasons that are not specifically listed in the exclusion section of the measure. Each is expected to be captured and made available for measurement or clinical decision support within the EHR workflow but the exact method or location of capture is a local or vendor decision.

Denominator, Numerator, Exclusion and Exception element guidance:
The criteria indicate scenarios in which the patient is admitted to the hospital directly or the patient is admitted from the Emergency Department (ED). The calculation is to indicate the timing from arrival at the facility to the occurrence of an event.

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All hospital discharges for acute myocardial infarction (AMI) with hospital stays <= 120 days during the measurement year for patients age 18 and older at the time of hospital admission with ST-elevation on electrocardiogram (ECG) who received primary percutaneous coronary intervention (PCI).

Patients age 18 and older with an ICD-9-CM Principal Diagnosis Code for AMI AND PCI (ICD-9-CM Principal and Other Procedure Codes for PCI) AND ST-segment elevation on the last ECG performed prior to hospital arrival or the first ECG performed after hospital arrival; AND PCI performed within 24 hours after hospital arrival.

Patients enrolled in clinical trials.
Patients received as a transfer from an inpatient or outpatient department of another hospital.
Patients received as a transfer from the emergency/observation department of another hospital.
Patients received as a transfer from an ambulatory surgery center.
Patients administered fibrinolytic agent prior to PCI
PCI described as non-primary by a physician/advanced practice nurse/physician assistant (physician/APN/PA).

AMI patients whose time from hospital arrival to primary PCI is 90 minutes or less.

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