[CQM-7456] OP-40 Tx's Created: 11/18/24 Updated: 12/03/24 Resolved: 12/02/24 |
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| Status: | Closed |
| Project: | eCQM Issue Tracker |
| Component/s: | None |
| Type: | Other | Priority: | Moderate |
| Reporter: | Sara Mitchell (Inactive) | Assignee: | Mathematica EH eCQM Team |
| Resolution: | Answered | Votes: | 0 |
| Labels: | None | ||
| Contact Name: | Sara Mitchell |
| Contact Email: | sara.mitchell900@commonspirit.org |
| Contact Phone: | 8057393343 |
| Institution/Name: | Dignity Health: Marian Regional Medical Center |
| Solution: | Thank you for your inquiry regarding CMS966v4, Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). Our understanding of this scenario is that a patient arrived at the ED without a STEMI diagnosis and was diagnosed with a STEMI during the ED encounter. The patient was then transferred to a PCI-capable facility and received the PCI at the receiving facility. Based on this, for the first question, we can confirm the patient is included in the measure denominator. The measure denominator captures all patients that arrive with a STEMI diagnoses or develops a STEMI during the ED encounter. For the second and third question, both facilities, the one that transfers the patient with a STEMI diagnosis and the facility that accepts a STEMI patient into the ED would receive a score. This measure captures the percentage of ED encounters for patients 18 years and older with a diagnosis of STEMI who received appropriate treatment, defined as fibrinolytic therapy within 30 minutes of ED arrival, PCI 90 minutes of ED arrival, or transfer to an Acute Care Facility within 45 minutes of ED arrival. As such, this case would be included in the measure’s denominator for both respective facilities, assuming none of the measure exclusion criteria apply. |
| Solution Posted On: | |
| 2024 Reporting Period Outpatient eCQMs: |
CMS0996v4
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| Impact: | Clarification on whether a patient can be counted twice in this metric. Our smaller sister hospital is not a STEMI receiving center, however they are on our TJC and CMS license. |
| Last Commented Date: |
| Description |
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A patient went into Hospital A (smaller non-STEMI receiving center), had work up, delayed in STEMI being called while in ED. EKG in triage was normal w/o signs ischemic changes. Later during the ED visit and workup, troponin resulted as mildly elevated 0.075, following this repeat EKG was positive for STEMI. Transfer to hospital B took 3H 26 min waiting for transport. Hospital A d/c diagnosis was STEMI, however it occurred after arrival. Patient was transferred to Hospital B (STEMI receiving center) and reperfusion was established < 50min after arrival time.
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| Comments |
| Comment by Sara Mitchell (Inactive) [ 12/03/24 ] |
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Both hospitals are on the same CMS hospital license. So either way this patient will be in our denominator. Thank you
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| Comment by Mathematica EH eCQM Team [ 11/27/24 ] |
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We continue to investigate the issue noted in your ticket and will provide a response as soon as we are able. Thank you for your patience. |
| Comment by Michele Zywiec [ 11/20/24 ] |
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ePC01v12 ePC-01 Elective Delivery 2023 |
| Comment by Mathematica EH eCQM Team [ 11/20/24 ] |
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Thank you for submitting your question. We will review your ticket and provide a response as soon as possible. |