How to manage meeting 45 minute departure when transferring from a more rural hospitals

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    • Type: Hosp Outpt eCQMs - Hospital Outpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Maya Frankenstein
    • 9704244551
    • St. Luke's Health System
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      Thank you for your inquiry regarding CMS996: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). The measure captures three potential numerators for patients aged 18 years or older that arrive to the ED with a STEMI diagnosis: PCI procedure within 90 minutes of ED arrival, fibrinolytic therapy within 30 minutes of ED arrival, or discharge to PCI-capable facility within 45 minutes of ED arrival. To meet the third numerator criterion, ED discharge with a discharge disposition of “Discharge to Acute Care Facility” must occur within 45 minutes of ED arrival, as indicated by the definition below found in the following human readable file: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS996v5.html.

       

      ED Departure with Transfer 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"

       

      This 45-minute timing threshold was chosen with comprehensive consideration and review from clinicians and experts in a Technical Expert Panel. Thank you for bringing the concern of air transport arrival time to rural facilities to our attention. CMS and the measure developer can consider refinements in a future Annual Update.
      Show
      Thank you for your inquiry regarding CMS996: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). The measure captures three potential numerators for patients aged 18 years or older that arrive to the ED with a STEMI diagnosis: PCI procedure within 90 minutes of ED arrival, fibrinolytic therapy within 30 minutes of ED arrival, or discharge to PCI-capable facility within 45 minutes of ED arrival. To meet the third numerator criterion, ED discharge with a discharge disposition of “Discharge to Acute Care Facility” must occur within 45 minutes of ED arrival, as indicated by the definition below found in the following human readable file: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS996v5.html .   ED Departure with Transfer 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"   This 45-minute timing threshold was chosen with comprehensive consideration and review from clinicians and experts in a Technical Expert Panel. Thank you for bringing the concern of air transport arrival time to rural facilities to our attention. CMS and the measure developer can consider refinements in a future Annual Update.
    • CMS0996v5
    • CMS0996v4
    • Patients are not meeting numerator criteria even though transfer was initiated within 45 minutes, but departure was not within 45 minutes

      One of our hospitals is 35-50 minutes out for the air transport to arrive, so we are not able to meet the 45 minute departure criteria for numerator. Is there or can we add a pathway for capturing this in the metric?

      Make a numerator inclusion pathway for initiation of transfer within a time frame or a denominator exclusion pathway for in-route transfer not arriving within 45 minutes

            Assignee:
            Augustine Weber
            Reporter:
            Maya Frankenstein
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              Created:
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