None
]]>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
]]>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
]]>Equals Initial Population
]]>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
]]>None
]]>Improvement noted as an increase in the rate
]]>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.
]]>None
]]>None
]]>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.
]]>There are known issues on CMS996v4. See issues EKI-25, EKI-26, and EKI-30 on the ONC eCQM Known Issues Dashboard for details.
]]>- 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 transferred within 45 minutes of ED arrival
]]>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 most recent dose 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
- 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, 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 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
]]>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.
]]>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.
]]>There is a known issue on CMS996v5. See issue EKI-38 on the ONC eCQM Known Issues Dashboard for details.
]]>- 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
]]>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
]]>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.
]]>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.
]]>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.
]]>There is a known issue on CMS996v6. See issue EKI-40 on the ONC eCQM Known Issues Dashboard for details.
]]>