Emergency Room Discharge Form Pa - DOC by asn15088

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									                                                                                     ED-AMI Measures
                                                                                        Data Elements
Data Element Name:              ED Admission Source

Collected For:                  All ED-AMI Measures

Definition:                     The source of emergency department admission for the patient.

Suggested Data
Collection Question:            What was the source of emergency department admission for the
                                patient?

Format:                         Length:        1
                                Type:          Alphanumeric
                                Occurs:        1

Allowable Values:               1       Physician referral
                                        The patient was referred to this facility for outpatient or
                                        referenced diagnositic services by his or her personal physician
                                        or the patient independently requested outpatient services (self-
                                        referral)

                                 2 Clinic referral
                                   The patient was referred to this facility for outpatient or
                                   referenced diagnostic services by this facility’s clinic or other
                                   outpatient department physician


                                  3 HMO referral
                                    The patient was referrred to this facility for outpatient or
                                    referenced diagnostic services by a health maintenance
                                    physician.

                                 4 Transfer from a hospital (Different Facility*)
                                   The patient was referred to this facility for outpatient or or
                                   referenced diagnostic services by (a physician of) a different
                                   acute care facility.
                                    *For Transfers from Hospital Inpatient in the Same
                                    Facility, see Code D

                                    5     Transfer from Skilled Nursing Facility
                                        The patient was referred to this facility for outpatient or
                                        referenced diagnostic services by (a physician of ) the skilled
                                        nursing facility where he or she is an inpatient.

                                 6      Transfer from Another Health Care Facility



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ED-AMI Measures
                                                                                       ED-AMI Measures
                                                                                          Data Elements
                                        The patient was referred to this facility for outpatient or
                                        referenced diagnostic services by (a physician of) another
                                        health care facility where he or she is an inatient.

                                    7     Emergency Room
                                        The patient received services in this facility’s emergency
                                        department.

                                    8     Court/Law Enforcement
                                        The patient was referred to this facility upon the direction of a
                                        court of law, or upon the requested of a law enforcement
                                        agency representative.

                                A Transfer from a Critical Access Hospital
                                  The patient was referred to this facility for outpatient or
                                  referenced diagnostic services by (a physician of ) the Critical
                                  Access Hospital where he or she was an inpatient.

                                D        Transfer from Hospital Inpatient in the Same Facility
                                         Resulting in a Separate Claim to the Payer
                                         The patient was admitted to the facility as a transfer from
                                         hospital inpatient within this facility resulting in a separate
                                         claim to the payer.

Notes for Abstraction:         Because this data element is critical in determining the
                               population for many measures, the abstractor should NOT
                               assume that the claim information for the admission source is
                               correct. If the abstractor determines through chart review
                               that the admission source is incorrect, she/he should correct
                               and override the downloaded value.

Suggested Data Sources:                Emergency department record


Guidelines for Abstraction:
                 Inclusion                                               Exclusion
 None                                                  None




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                  ED-AMI Measures
                                                                                     Data Elements
Data Element Name:              ED Arrival Date

Collected For:                  All ED-AMI Measures

Definition:                     The earliest documented month, day, and year the patient arrived at
                                the emergency department.

Suggested Data
Collection Question:            What was the earliest documented date the patient arrived at the
                                emergency department?

Format:                         Length:    10 – MM-DD-YYYY (includes dashes) or UTD
                                Type:      Date
                                Occurs:    1

Allowable Values:               Enter the earliest documented date
                                MM =       Month (01-12)
                                DD =       Day (01-31)
                                YYYY = Year (2000-9999)
                                UTD =       Unable to Determine

Notes for Abstraction:             If the date of arrival is unable to be determined from medical
                                    record documentation, enter UTD.
                                   Review only the acceptable sources to determine the earliest
                                    date the patient arrived at the emergency department.
                                   NOTE: Medical record documentation from all of the “only
                                    acceptable sources” should be carefully examined in
                                    determining the most correct date of arrival. Arrival date
                                    should NOT be abstracted simply as the earliest date in the
                                    acceptable sources, without regard to other (i.e., ancillary
                                    services) substantiating documentation. If documentation
                                    suggests that the earliest date in the acceptable sources does not
                                    reflect the date the patient arrived at the emergency
                                    department, this date should not be used.




Notes for Abstraction
continued:
                                   The source “Procedure notes” refers to formal documents that
                                    describe a procedure that was done (e.g., endoscopy, cardiac
                                    cath).

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Hospital Quality Measures Special Study
ED-AMI Measures
                                                                      ED-AMI Measures
                                                                         Data Elements


Suggested Data Sources:        ONLY ACCEPTABLE SOURCES:
                                Emergency department record
                                Observation record
                                Procedure notes
                                Vital signs graphic record


Guidelines for Abstraction:
                 Inclusion                                Exclusion
 None                                        None




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                 ED-AMI Measures
                                                                                    Data Elements
Data Element Name:              ED Arrival Time

Collected For:                  ED-AMI-2, ED-AMI-3, ED-AMI-4, ED-AMI-5

Definition:                     The earliest documented time (military time) the patient arrived at
                                the emergency department.

Suggested Data
Collection Question:            What was the earliest documented time the patient arrived at the
                                emergency department?

Format:                         Length:    5 - HH:MM (includes colon) or UTD
                                Type:      Time
                                Occurs:    1

Allowable Values:               Enter the earliest documented time of arrival
                                HH = Hour (00-23)
                                MM = Minutes (00-59)
                                UTD = Unable to Determine

                                Military Time – A 24-hour period from
                                midnight to midnight using a 4-digit number of which the first two
                                digits indicate the hour and the last two digits indicate the minute.

                                Converting clock time to military time:
                                With the exception of Midnight and Noon:
                                 If the time is in the a.m., conversion is not required
                                 If the time is in the p.m., add 12 to the clock time hour

                                For example:
                                Midnight - 00:00       Noon - 12:00
                                5:31 am - 05:31        5:31 pm - 17:31
                                11:59 am - 11:59       11:59 pm - 23:59

Notes for Abstraction:             If the time of arrival is unable to be determined from medical
                                    record documentation, enter UTD.
                                   Review only the acceptable sources to determine the earliest
                                    time the patient arrived at the emergency department.
                                   NOTE: Medical record documentation from all of the “only
                                    acceptable sources” should be carefully examined in
                                    determining the most correct time of arrival. Arrival time
                                    should NOT be abstracted simply as the earliest time in the
Notes for Abstraction               acceptable sources, without regard to other (i.e., ancillary
continued:                          services) substantiating documentation. If documentation
                                    suggests that the earliest time in the acceptable sources does
                                    not reflect the time the patient arrived at the emergency
Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                               ED-AMI Measures
                                                                                  Data Elements
                                    department, this time should not be used.
                                   The source “Procedure notes” refers to formal documents that
                                    describe a procedure that was done (e.g., endoscopy, cardiac
                                    cath). ECG and x-ray reports should NOT be considered
                                    procedure notes.

Suggested Data Sources:        ONLY ACCEPTABLE SOURCES:
                                Emergency department record
                                Observation record
                                Procedure notes
                                Vital signs graphic record


Guidelines for Abstraction:
                 Inclusion                                        Exclusion
 None                                            None




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                 ED-AMI Measures
                                                                                    Data Elements
Data Element Name:              ED Aspirin Received

Collected For:                  ED-AMI-1

Definition:                     Aspirin received within 24 hours before emergency department
                                arrival or prior to transfer. Aspirin is primarily a pain reliever.
                                Aspirin also reduces the tendency of blood to clot by blocking the
                                action of a type of blood cell involved in clotting. Aspirin reduces
                                the risk of having a heart attack and improves chances of surviving
                                a heart attack.

Suggested Data
Collection Question:            Was aspirin received within 24 hours before emergency
                                department arrival or prior to transfer?

Format:                         Length:    1
                                Type:      Alphanumeric
                                Occurs:    1

Allowable Values:               Y (Yes) Aspirin received within 24 hours before emergency
                                        department arrival or prior to transfer.

                                N (No)     Aspirin not received within 24 hours before emergency
                                           department arrival or prior to transfer or unable to
                                           determine from medical record documentation.

Notes for Abstraction:           When unable to determine for certain whether aspirin was
                                  received within 24 hours prior to emergency department arrival
                                  (e.g., last dose noted as 02-27-2006 and patient arrived at
                                  emergency department on 02-28-2006 at 09:00), select “No.”
                                  Exceptions:
                                 When aspirin is listed only as a home or "current" medication,
                                  and the exact timing of the last dose the patient took is not
                                  noted, infer that the patient took aspirin within the 24 hour
                                  timeframe, unless documentation suggests otherwise.
                                 When aspirin is noted only as received prior to emergency
                                  department arrival, without information about the exact time it
                                  was received (e.g., "Baby ASA X 4" per the "Treatment Prior
                                  to Arrival" section of the Triage Assessment), infer that the
                                  patient took aspirin within the 24 hour timeframe, unless
                                  documentation suggests otherwise.



Suggested Data Sources:            Ambulance record
                                   Emergency department record
Oklahoma Foundation for Medical Quality
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                                                                        ED-AMI Measures
                                                                           Data Elements
                                   Transfer sheet

Guidelines for Abstraction:
                 Inclusion                                  Exclusion
 Refer to Appendix C, Table 1.1 for a                None
 comprehensive list of Aspirin and Aspirin-
 Containing Medications.




Oklahoma Foundation for Medical Quality
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ED-AMI Measures
                                                                                   ED-AMI Measures
                                                                                      Data Elements
Data Element Name:              ED Birthdate

Collected For:                  All ED-AMI Measures

Definition:                     The month, day, and year the patient was born.

                                NOTE: Patient's age (in years) is calculated by ED Arrival Date
                                minus ED Birthdate. The algorithm to calculate age must use the
                                month and day portion of emerency department arrival date and
                                emergency department birthdate to yield the most accurate age.

Suggested Data
Collection Question:            What is the patient’s date of birth?

Format:                         Length:    10 – MM-DD-YYYY (includes dashes)
                                Type:      Date
                                Occurs:    1

Allowable Values:               MM =   Month (01-12)
                                DD =   Day (01-31)
                                YYYY = Year (1880-9999)

Notes for Abstraction:         Because this data element is critical in determining the population
                               for all measures, the abstractor should NOT assume that the claim
                               information for the birthdate is correct. If the abstractor determines
                               through chart review that the date is incorrect, she/he should correct
                               and override the downloaded value. If the abstractor is unable to
                               determine the correct birthdate through chart review, she/he should
                               default to the date of birth on the claim information.

Suggested Data Sources:            Emergency department record
                                   Face sheet
                                   Registration form


Guidelines for Abstraction:
                 Inclusion                                             Exclusion
 None                                             None




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                ED-AMI Measures
                                                                                   Data Elements
Data Element Name:              ED Comfort Measures Only

Collected For:                  All ED-AMI Measures

Definition:                     Physician/advanced practice nurse/physician assistant
                                (physician/APN/PA) documentation the patient was receiving
                                comfort measures only. Commonly referred to as “palliative care”
                                in the medical community and “comfort care” by the general
                                public. Palliative care includes attention to the psychological and
                                spiritual needs of the patient and support for the dying patient and
                                the patient's family. Usual interventions are not received because a
                                medical decision was made to limit care to comfort measures only.
                                Comfort Measures Only are not equivalent to the following: Do
                                Not Resuscitate (DNR), living will, no code, no heroic measure.

Suggested Data
Collection Question:            Is there physician/APN/PA documentation the patient was
                                receiving comfort measures only?

Format:                         Length:    1
                                Type:      Alphanumeric
                                Occurs:    1

Allowable Values:               Y (Yes) There is physician/APN/PA documentation that the
                                        patient was receiving “comfort measures only” anytime
                                        during the emergency department stay.

                                N (No)     There is no physician/APN/PA documentation the
                                           patient was receiving “comfort measures only” anytime
                                           during the emergency department stay or unable to
                                           determine from medical record documentation.

Notes for Abstraction:            Only accept terms identified in the list of inclusions. No
                                   other terminology will be accepted.
                                 If the only documentation of comfort measures only is a
                                   reference to care planned after discharge, and comfort
                                   measures only was not a directed treatment while the patient
                                   was in the emergency department, select “No.”
                                 If DNR-CC is documented, select “No,” unless there is
                                  documented clarification that CC stands for “comfort care.”
                                 If any of the inclusions are documented, select “Yes,”
                                  regardless of other documentation.

Suggested Data Sources:         PHYSICIAN/APN/PA DOCUMENTATION ONLY
                                 Physician orders
                                 Emergency department record
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ED-AMI Measures
                                                                               ED-AMI Measures
                                                                                  Data Elements
                                   Physician notes

Guidelines for Abstraction:
                 Inclusion                                           Exclusion
  Comfort care                                      Chemical code only
  Comfort measures                                  Do not cardiovert
  Comfort measures only (CMO)                       Do not defibrillate
  End of life care                                  Do not intubate (DNI)
  Hospice care                                      Do Not Resuscitate (DNR)
  Palliative care                                   Keep comfortable
  Terminal care                                     Living will
                                                     No aggressive treatment
                                                     No antiarrhythmic therapy
                                                     No artificial respirations
                                                     No cardiac monitoring
                                                     No Cardiopulmonary Resuscitation
                                                      (NCR)
                                                     No chest compressions
                                                     No code
                                                     No Code 99
                                                     No CPR
                                                     No heroic or aggressive measures
                                                     No intubation and/or ventilation
                                                     No invasive procedures
                                                     No other protocols associated with
                                                      advanced cardiac life support
                                                     No resuscitative medications
                                                     No resuscitative measures (NRM)
                                                     No vasopressors
                                                     Supportive care




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ED-AMI Measures
                                                                                 ED-AMI Measures
                                                                                    Data Elements
Data Element Name:              ED Contraindication to Aspirin on Arrival

Collected For:                  ED-AMI-1

Definition:                     Contraindications/reasons for not prescribing aspirin on arrival to
                                the emergency department include: aspirin allergy,
                                Coumadin/warfarin as pre-arrival medication, or other reasons
                                documented by physician/advanced practice nurse/physician
                                assistant (physician/APN/PA) for not giving aspirin on arrival.
                                Aspirin is primarily a pain reliever. Aspirin also reduces the
                                tendency of blood to clot by blocking the action of a type of blood
                                cell involved in clotting. Aspirin reduces the risk of having a heart
                                attack and improves chances of surviving a heart attack.

Suggested Data
Collection Question:            Select one of the following potential contraindications or reasons
                                for not prescribing aspirin present on arrival?

Format:                         Length:    1
                                Type:      Alphanumeric
                                Occurs:    1

Allowable Values:               1   Allergy/Sensitivity to aspirin: There is documentation
                                    of an aspirin allergy/sensitivity.

                                2   Documentation of Coumadin/Warfarin prescribed pre-
                                    arrival: Coumadin/Warfarin is prescribed as a pre-arrival
                                    medication.

                                3   Other documented reasons: There is another reason
                                    documented by a physician/APN/PA for not prescribing aspirin
                                    on arrival.

                                4   No documented contraindication/reason or Unable to
                                    determine (UTD): There is no documentation of
                                    contraindications/reasons for not prescribing aspirin on arrival
                                    or unable to determine from medical record documentation

Notes for Abstraction:             This data element should be answered independently and
                                    irrespective of whether the patient was prescribed aspirin
                                    on arrival.
                                   When there is documentation of an aspirin “allergy” or
                                    “sensitivity,” regard this as documentation of an aspirin
                                    allergy regardless of what type of reaction might be noted: Do
                                    not attempt to distinguish between true allergies/sensitivities
                                    and intolerances, side effects, etc. (e.g., “Allergies: ASA –

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                                                                                  ED-AMI Measures
                                                                                     Data Elements
                                    Upsets stomach” – select “1.”)
                                 Documentation of an allergy/sensitivity to one particular type
                                    of aspirin is acceptable to take as an allergy to the entire class
                                    of aspirin-containing medications (e.g., “Allergic to
                                    Empirin”).
                                 When determining whether Coumadin/warfarin was a pre-
                                    arrival medication:
                                    o Refer to the patient’s medication regimen just prior to
                                        emergency department treatment. Include
                                        Coumadin/warfarin if the patient was on it at home, the
                                        nursing home, a transferring psychiatric hospital, etc. Do
                                        NOT include Coumadin/ warfarin taken in the ambulance
                                        en route to the hospital.
                                    o Include cases where there is documentation that the
                                        patient was prescribed Coumadin/warfarin at home but
                                        there is indication it was on temporary hold or the patient
                                        has been non-compliant/self-discontinued their medication
                                        (e.g., refusal, side effects, cost).
                               Other reasons include any physician/APN/PA documentation of a
                               reason for not prescribing aspirin. (e.g. ASA not prescribed for xxx)
                               There must be a documented reason. Documentation of “Aspirin
                               not prescribed” or “do not give aspirin” will not be sufficient.
                                    o Physician/APN/PA crossing out of an aspirin order counts
                                        as an "other reason" for not prescribing aspirin on arrival
                                 Notation of an aspirin allergy prior to arrival counts as a
                                    contraindication to aspirin on arrival.
                                 Pre-arrival hold or discontinuation of aspirin or notation such
                                    as "No aspirin" counts as a reason for not prescribing aspirin
                                    on arrival.
                                 Pre-arrival "other reason" counts as reason for not prescribing
                                    aspirin on arrival (e.g., "Intolerance to aspirin", "Hx GI
                                    bleeding with aspirin").

Suggested Data Sources:            Consultation notes
                                   Emergency department record
                                   Nursing notes
                                   Physician orders
                                   Transfer sheet




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                             ED-AMI Measures
                                                                                Data Elements
Guidelines for Abstraction:
                 Inclusion                                      Exclusion
 Refer to Appendix C, Table 1.1 for a          Aspirin Allergy
 comprehensive list of Aspirin and Aspirin-    Aspirin allergy described using one of the
 Containing medications.                       negative modifiers or qualifiers listed in
                                               Appendix H, Table 2.6, Qualifiers and
 Refer to Appendix C, Table 1.4 for a          Modifiers Table
 comprehensive list of Warfarin medications.




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                 ED-AMI Measures
                                                                                    Data Elements
Data Element Name:              ED Discharge Date

Collected For:                  ED-AMI-1, ED-AMI-5

Definition:                     The month, day, and year the patient was discharged from the
                                emergency department, left against medical advice, or expired
                                during this stay.

Suggested Data
Collection Question:            What is the date the patient was discharged from the emergency
                                department, left against medical advice (AMA), or expired?

Format:                         Length:    10 – MM-DD-YYYY (includes dashes)
                                Type:      Date
                                Occurs:    1

Allowable Values:               MM =   Month (01-12)
                                DD =   Day (01-31)
                                YYYY = Year (2000-9999)

Notes for Abstraction:          Because this data element is critical in determining the population
                                for many measures, the abstractor should NOT assume that the
                                claim information for the discharge date is correct. If the
                                abstractor determines through chart review that the date is
                                incorrect, she/he should correct and override the downloaded
                                value. If the abstractor is unable to determine the correct discharge
                                date through chart review, she/he should default to the discharge
                                date on the claim information.

Suggested Data Sources:            Discharge summary
                                   Nursing discharge notes
                                   Physician orders
                                   Transfer note


Guidelines for Abstraction:
                 Inclusion                                         Exclusion
 None                                             None




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                 ED-AMI Measures
                                                                                    Data Elements
Data Element Name:              ED Discharge Status

Collected For:                  All ED-AMI Measures

Definition:                     The place or setting to which the patient was discharged.

Suggested Data
Collection Question:            What was the patient’s discharge disposition?

Format:                         Length:    2
                                Type:      Alphanumeric
                                Occurs:    1

Allowable Values:               01 Discharged to home care or self care (routine discharge)

                                02 Discharged/transferred to a short term general hospital for
                                   inpatient care (Acute Care Facility)

                                03 Discharged/transferred to skilled nursing facility (SNF)
                                   with Medicare certification in anticipation of covered
                                   skilled care
                                   Usage Note: Medicare-indicates that the patient is
                                   discharged/transferred to a Medicare certified nursing facility.
                                   For hospitals with an approved swing bed arrangement, use
                                   Code 61-Swing Bed. For reporting other discharges/transfers
                                   to nursing facilities, see 04 and 64.

                                04 Discharged/transferred to an intermediate care facility
                                   (ICF)
                                   Usage Note: Typically defined at the state level for specifically
                                   designated intermediate care facilities. Also used to designate
                                   patients that are discharged/transferred to a nursing facility
                                   with neither Medicare nor Medicaid certification and for
                                   discharges/transfers to state designated Assisted Living
                                   Facilities.

                                05 Discharged/transferred to a non-Medicare PPS children’s
                                   hospital or a non-Medicare PPS cancer hospital for
                                   inpatient care.




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                                                                              ED-AMI Measures
                                                                                    Data Elements
Allowable Values                06 Discharged/transferred to home under care of organized
continued:                         home health service organization in anticipation of covered
                                   skilled care
                                   Usage Note: Report this code when the patient is
                                   discharged/transferred to home with a written plan of care
                                   for home care services.

                                07 Left against medical advice or discontinued care

                                09 Admitted as an inpatient to this hospital
                                   Usage Note: For use only on Medicare outpatient claims.
                                   Applies only to those Medicare outpatient services that begin
                                   greater than three days prior to an admission.

                                20 Expired

                                41 Expired in a medical facility (e.g., hospital, SNF, ICF or
                                   freestanding hospice)
                                   Usage Note: For use only on Medicare and CHAMPUS
                                   (TRICARE) claims for hospice care.

                                43 Discharged/transferred to a federal health care facility
                                   Usage Note: Discharges and transfers to a government operated
                                   health care facility such as a Department of Defense hospital, a
                                   Veteran’s Administration hospital or a Veteran’s
                                   Administration nursing facility. To be used whenever the
                                   destination at discharge is a federal health care facility, whether
                                   the patient resides there or not.

                                50 Hospice - home

                                51 Hospice - medical facility

                                61 Discharged/transferred to hospital-based Medicare
                                   approved swing bed
                                   Usage Note: Medicare-used for reporting patients discharged/
                                   transferred to a SNF level of care within a hospital's approved
                                   swing bed arrangement.

                                62 Discharged/transferred to an inpatient rehabilitation
                                   facility (IRF) including rehabilitation distinct part units of
                                   a hospital

                                63 Discharged/transferred to a Medicare certified long term
                                   care hospital (LTCH)
                                   Usage Note: For hospitals that meet the Medicare criteria for
                                   LTCH certification.
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                                  64 Discharged/transferred to a nursing facility certified under
                                     Medicaid but not certified under Medicare

                                  65 Discharged/transferred to a psychiatric hospital or
                                     psychiatric distinct part of a hospital

                                  66 Discharged/transferred to a Critical Access Hospital (CAH)

                                  70 Discharged/transferred to another type of institution not
                                     defined elsewhere in this code list

Allowable Values
continued:

                                  NOTE: CMS and the Joint Commission are aware that there are
                                  additional UB-92 or UB-04* allowable values for this data
                                  element; however, they are not used for the national quality
                                  measures set at this time.

Notes for Abstraction:                The values for Discharge Status are taken from the National
                                       Uniform Billing Committee (NUBC) manual which is used by
                                       the billing/HIM to complete the UB-92 or UB-04*.
                                      Because this data element is critical in determining the
                                       population for many measures, the abstractor should NOT
                                       assume that the UB-92 or UB-04* value is what is reflected in
                                       the medical record. For abstraction purposes, it is important
                                       that the medical record reflect the appropriate discharge status.
                                       If the abstractor determines through chart review that the claim
                                       information discharge status is not what is reflected in the
                                       medical record, she/he should correct and override the
                                       downloaded value.


Suggested Data                       Discharge instruction sheet
Sources:                             Nursing discharge notes
                                     Physician orders
                                     Transfer record

Guidelines for Abstraction:
                  Inclusion                                            Exclusion
 Refer to Appendix H, Table 2.5 Discharge            None
 Status Disposition.




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                  ED-AMI Measures
                                                                                     Data Elements
Data Element Name:              ED Discharge Time

Collected For:                  ED-AMI-5

Definition:                     The exact time (military time) represented in hours and minutes, at
                                which the patient was discharged from the emergency department,
                                left against medical advice (AMA), or expired during this stay.

Suggested Data
Collection Question:            What was the time the patient was discharged from the emergency
                                department, left against medical advice (AMA), or expired during
                                this stay?

Format:                         Length:    5 – HH:MM (includes colon) or UTD
                                Type:      Time
                                Occurs:    1

Allowable Values:               HH = Hour (00-23)
                                MM = Minutes (00-59)
                                UTD = Unable to Determine

                                Military Time – A 24-hour period from midnight to midnight using
                                a 4-digit number of which the first two digits indicate the hour and
                                the last two digits indicate the minute.

                                Converting clock time to military time:
                                With the exception of Midnight and Noon:
                                 If the time is in the a.m., conversion is not required.
                                 If the time is in the p.m., add 12 to the clock time hour.

                                For example:
                                Midnight – 00:00       Noon – 12:00
                                5:31 am – 05:31        5:31 pm – 17:31
                                11:59 am – 11:59       11:59 pm – 23:59

Notes for Abstraction:             If the time the patient was discharged is unable to be
                                    determined from medical record documentation, enter UTD.
                                   Use the Priority order listed in the Suggested Data Sources.
                                   When more than one discharge time is documented in the
                                    highest priority suggested data source, abstract the latest time.
                                    Examples:
                                    o Two discharge times are found in the nurse’s notes: 12:03
                                         and 12:20. Select the later time of 12:20.
                                    o A discharge time of 15:30 is found in the nurses notes. A
                                         discharge time of 15:50 is also documented on the transfer
Notes for Abstraction                   form. Abstract 15:30 because the nurse’s notes are a higher
continued:                              priority source.
                                   If the patient expired, use the time of death as the discharge
Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                 ED-AMI Measures
                                                                                    Data Elements
                                    time.
                                   Do not use the time the discharge order was written because it
                                    may not represent the actual time of discharge.
                                   If the patient was discharged, but the face sheet, discharge form
                                    or time documented in the nurse’s notes could not be located,
                                    use the UB-92, Field Location: 21 or UB-04*, Field Location:
                                    16.
                                    Example: If the UB-92, Field Location: 21 is used and states
                                    “22,” enter “22:00” as the time of discharge.

Suggested Data Sources:         For patients who are discharged from the emerency department,
                                left AMA, or transferred to another facility (priority order):
                                 Nurses notes
                                 Discharge or transfer form
                                 UB-92, Field Location: 21
                                 UB-04*, Field Location: 16

                                For patients who expire (priority order):
                                 Death record
                                 Resuscitation record
                                 Physician progress notes
                                 Physician orders
                                 Nurses notes

Guidelines for Abstraction:
                 Inclusion                                         Exclusion
 None                                             None




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                ED-AMI Measures
                                                                                   Data Elements
Data Element Name:              ED ECG

Collected For:                  ED-AMI-4

Definition:                     Documentation a 12 lead electrocardiogram (ECG) is performed
                                prior to emergency department arrival or prior to transfer.

Suggested Data
Collection Question:            Was an ECG done within 1 hour before emergency department
                                arrival or prior to transfer?

Format:                         Length:    1
                                Type:      Alphanumeric
                                Occurs:    1

Allowable Values:               Y (Yes) There was an ECG done within 1 hour before
                                        emergency department arrival or prior to transfer.

                                N (No)     There was not an ECG done within 1 hour before
                                           emergency department arrival or prior to transfer.

Notes for Abstraction:           If there is an ECG done exactly one hour prior to arrival select
                                  “Yes”.
                                 If there are multiple ECG’s done within one hour prior to
                                  emergency department arrival and prior to transfer, select
                                  “Yes”.

Suggested Data Sources:            Ambulance record
                                   ECG report
                                   Emergency department record
                                   Nursing notes
                                   Physician documentation
                                   Transfer sheet


Guidelines for Abstraction:
                 Inclusion                                         Exclusion
 ECG’s done in the ambulance                     None




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                ED-AMI Measures
                                                                                   Data Elements
Data Element Name:              ED ECG Date

Collected For:                  ED-AMI-4

Definition:                     The documented month, day, and year of the ECG.

Suggested Data
Collection Question:            What was the documented date of the ECG.

Format:                         Length:    10 – MM-DD-YYYY (includes dashes) or UTD
                                Type:      Date
                                Occurs:    1

Allowable Values:               Enter the earliest documented date of the ECG
                                MM =       Month (01-12)
                                DD =       Day (01-31)
                                YYYY = Year (2000-9999)
                                UTD =       Unable to Determine

Notes for Abstraction:
 If the date of the ECG is unable to be determined from medical record documentation, enter
    UTD.
 ECGs obtained prior to arrival abstract as the arrival date

Suggested Data Sources:            Any ED documentation
                                   Ambulance record
                                   ECG report
                                   Nursing notes
                                   Procedure notes


Guidelines for Abstraction:
                 Inclusion                                       Exclusion
 None                                            None




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                 ED-AMI Measures
                                                                                    Data Elements
Data Element Name:              ED ECG Time

Collected For:                  ED-AMI-4

Definition:                     The earliest documented time (military time) of the initial 12-lead
                                ECG performed.

Suggested Data
Collection Question:            What was the earliest documented time of the initial 12-lead ECG
                                performed?

Format:                         Length:    5 - HH:MM (includes colon) or UTD
                                Type:      Time
                                Occurs:    1

Allowable Values:               Enter the earliest documented time of the 12-lead ECG performed
                                HH = Hour (00-23)
                                MM = Minutes (00-59)
                                UTD = Unable to Determine

                                Military Time – A 24-hour period from
                                midnight to midnight using a 4-digit number of which the first two
                                digits indicate the hour and the last two digits indicate the minute.

                                Converting clock time to military time:
                                With the exception of Midnight and Noon:
                                 If the time is in the a.m., conversion is not required
                                 If the time is in the p.m., add 12 to the clock time hour

                                For example:
                                Midnight - 00:00       Noon - 12:00
                                5:31 am - 05:31        5:31 pm - 17:31
                                11:59 am - 11:59       11:59 pm - 23:59

Notes for Abstraction:                If the time of the ECG is unable to be determined from
                                     medical record documentation, enter UTD.
                                     ECGs obtained within one hour prior to arrival abstract as
                                     the arrival time
                                     ECG’s done exactly one hour prior to arrival abstract as
                                     arrival time
                                     If there are multiple times documented for the ECG,
                                     abstract the time closest to arrival time

Suggested Data Sources:            Any ED documentation
                                   ECG Report
                                   Procedure notes

Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                             ED-AMI Measures
                                                                Data Elements

Guidelines for Abstraction:
                 Inclusion                       Exclusion
 None                                     None




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                  ED-AMI Measures
                                                                                     Data Elements
Data Element Name:              ED Fibrinolytic Administration

Collected For:                  ED-AMI-2, ED-AMI-3

Definition:                     The patient received primary fibrinolytic therapy at this facility?
                                Fibrinolytic therapy is the administration of a pharmacological
                                agent intended to cause lysis of a thrombus (destruction or
                                dissolution of a blood clot).

Suggested Data
Collection Question:            Was primary fibrinolytic therapy received at this facility?

Format:                         Length:    1
                                Type:      Alphanumeric
                                Occurs:    1

Allowable Values:               Y (Yes) Primary fibrinolytic therapy administered at this
                                        facility.

                                N (No)     No primary fibrinolytic therapy administered at this
                                           facility, or unable to determine from medical record
                                           documentation.

Notes for Abstraction:             In the event the patient was brought to the hospital via
                                    ambulance and fibrinolytic therapy was infusing at the time of
                                    arrival, select “Yes.”
                                   In the event the patient was brought to the emergency
                                    department via ambulance and fibrinolytic therapy was infused
                                    during transport but was completed at the time of emergency
                                    department arrival, select “No.”

Suggested Data Sources:            Discharge summary
                                   Emergency department record
                                   Nursing flow sheets
                                   IV flow sheets
                                   Nursing notes

Guidelines for Abstraction:
                 Inclusion                                          Exclusion
 Refer to Appendix C, Table 1.5 for a             None
 comprehensive list of Fibrinolytic Agents.




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                     ED-AMI Measures
                                                                                        Data Elements
Data Element Name:              ED Fibrinolytic Administration Date

Collected For:                  ED-AMI-2, ED-AMI-3

Definition:                     The month, day, and year primary fibrinolytic therapy was initiated
                                at this facility. Fibrinolytic therapy is the administration of a
                                pharmacological agent intended to cause lysis of a thrombus
                                (destruction or dissolution of a blood clot).

Suggested Data
Collection Question:            What was the date primary fibrinolytic therapy was initiated at this
                                facility?

Format:                         Length:     10 - MM-DD-YYYY (includes dashes) or UTD
                                Type:       Date
                                Occurs:     1

Allowable Values:               MM =       Month (01-12)
                                DD =       Day (01-31)
                                YYYY =     Year (2000-9999)
                                UTD =      Unable to Determine

Notes for Abstraction:             If the date primary fibrinolytic therapy was initiated is unable
                                    to be determined from medical record documentation, enter
                                    UTD.
                                   If there were two different fibrinolytic administration episodes,
                                    enter the earliest date a fibrinolytic was initiated at this facility.
                                   In the event the patient was brought to the emergency
                                    department via ambulance and fibrinolytic therapy was
                                    infusing at the time of emergency department arrival, enter the
                                    date the patient arrived at this emergency department.

Suggested Data Sources:            Ambulance record
                                   Emergency department record
                                   IV flow sheets
                                   Nursing notes
                                   Transfer sheet


Guidelines for Abstraction:
                 Inclusion                                            Exclusion
 None                                               None




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                 ED-AMI Measures
                                                                                    Data Elements
Data Element Name:              ED Fibrinolytic Administration Time

Collected For:                  ED-AMI-2, ED-AMI-3

Definition:                     The time (military time) that primary fibrinolytic therapy started.
                                Fibrinolytic therapy is the administration of a pharmacological
                                agent intended to cause lysis of a thrombus (destruction or
                                dissolution of a blood clot).

Suggested Data
Collection Question:            What was the time primary fibrinolytic therapy was initiated at this
                                emergency department?

Format:                         Length:    5 - HH:MM (includes colon) or UTD
                                Type:      Time
                                Occurs:    1

Allowable Values:               HH = Hour (00-23)
                                MM = Minutes (00-59)
                                UTD = Unable to Determine

                                Military Time – A 24-hour period from midnight to midnight using
                                a 4-digit number of which the first two digits indicate the hour and
                                the last two digits indicate the minute.

                                Converting clock time to military time:
                                With the exception of Midnight and Noon:
                                 If the time is in the a.m., conversion is not required
                                 If the time is in the p.m., add 12 to the clock time hour

                                For example:
                                Midnight = 00:00       Noon = 12:00
                                5:31 am = 05:31        5:31 pm = 17:31
                                11:59 am = 11:59       11:59 pm = 23:59
Notes for Abstraction:           If the time primary fibrinolytic therapy was initiated is unable
                                   to be determined from medical record documenation, enter
                                   UTD.
                                 If there were two different fibrinolytic administration episodes,
                                   enter the time the earliest fibrinolytic was initiated during this
                                   emergency department stay.
                                 In the event the patient was brought to the hospital via
                                   ambulance and fibrinolytic therapy was infusing at the time of
                                   emergency department arrival, enter the time the patient
                                   arrived at this emergency department.

Suggested Data Sources:            Ambulance record
                                   Emergency department record
Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                    ED-AMI Measures
                                                                       Data Elements
                                   IV flow sheets
                                   Nursing notes
                                   Transfer sheet

Guidelines for Abstraction:
                 Inclusion                              Exclusion
 None                                            None




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                ED-AMI Measures
                                                                                   Data Elements
Data Element Name:              ED ICD-9-CM Other Diagnosis Codes

Collected For:                  All ED-AMI Measures

Definition:                     The International Classification of Diseases, Ninth Revision,
                                Clinical Modification (ICD-9-CM) codes associated with the
                                diagnosis for this record.

Suggested Data
Collection Question:            What were the ICD-9-CM admit diagnosis, other diagnosis, or
                                secondary codes selected for this medical record?

Format:                         Length:    6 (implied decimal point)
                                Type:      Alphanumeric
                                Occurs:    17

Allowable Values:               Any valid ICD-9-CM diagnosis code

Notes for Abstraction:          None

Suggested Data Sources:            Discharge summary
                                   UB-92 (Other Diagnosis Codes), Field Location: 68-75
                                   UB-04*, Field Locations: 67A-Q
                                    NOTE: Medicare will only accept codes listed in fields A-H

Guidelines for Abstraction:
                 Inclusion                                         Exclusion
 None                                             None




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                 ED-AMI Measures
                                                                                    Data Elements
Data Element Name:              ED ICD-9-CM Principal Diagnosis Code

Collected For:                  All ED-AMI Measures

Definition:                     The International Classification of Diseases, Ninth Revision,
                                Clinical Modification (ICD-9-CM) code associated with the
                                diagnosis established after study to be chiefly responsible for
                                occasioning the admission of the patient for this record.

Suggested Data
Collection Question:            What was the ICD-9-CM code selected as the principal or first
                                listed diagnosis for this record?

Format:                         Length:    6 (implied decimal point)
                                Type:      Alphanumeric
                                Occurs:    1

Allowable Values:               Any valid ICD-9-CM diagnosis code

Notes for Abstraction:          The principal diagnosis is defined in the Uniform Hospital
                                Discharge Data Set (UHDDS) as “that condition established after
                                study to be chiefly responsible for occasioning the admission of the
                                patient to the hospital for care.”

Suggested Data Sources:            Discharge summary
                                   UB-92, Field Location: 67
                                   UB-04*, Field Location: 67

Guidelines for Abstraction:
                 Inclusion                                          Exclusion
 Refer to Appendix A, for ICD-9-CM Code           None
 Tables




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                                 ED-AMI Measures
                                                                                    Data Elements
Data Element Name:              ED Initial ECG Interpretation

Collected For:                  ED-AMI-2, ED-AMI-3

Definition:                     ST-segment elevation or a left bundle branch block (LBBB) based
                                on the documentation of the electrocardiogram (ECG) performed
                                closest to emergency department arrival. The normal ECG is
                                composed of a P wave (atrial depolarization), Q, R, and S waves
                                (QRS complex, ventricular depolarization), and a T wave
                                (ventricular repolarization). The ST-segment, the segment
                                between the QRS complex and the T wave, may be elevated when
                                myocardial injury (AMI) occurs. Between the atria and the
                                ventricles, the conduction system divides electrical impulses into
                                right and left bundle branches. A bundle branch block (BBB)
                                results from impaired conduction in one branch, which in turn
                                results in abnormal ventricular depolarization. In LBBB, left
                                ventricular depolarization is delayed, resulting in a characteristic
                                widening of the QRS complex on the ECG. LBBB may be an
                                electrocardiographic manifestation of an AMI.

Suggested Data
Collection Question:            Is there documentation of ST-segment elevation or left bundle
                                branch block (LBBB) on the electrocardiogram (ECG) performed
                                closest to emergency department arrival?

Format:                         Length:    1
                                Type:      Alphanumeric
                                Occurs:    1

Allowable Values:               Y (Yes) ST-segment elevation or a LBBB on the interpretation
                                        of the 12-lead ECG performed closest to emergency
                                        department arrival.

                                N (No)     No ST-elevation or LBBB on the interpretation of the
                                           12-lead ECG performed closest to emergency
                                           department arrival, no interpretation or report available
                                           for the ECG performed closest to emergency
                                           department arrival or unable to determine from medical
                                           record documentation.

Notes for Abstraction:             Use the 12-lead ECG performed closest to the time of
                                    emergency department arrival, whether prior to or after
                                    emergency department arrival (e.g., 12-lead ECG done in the
                                    ambulance 10 minutes before emergency department arrival
                                    and a second one done in the ED 30 minutes after arrival – use
                                    the ECG done in the ambulance). If there is no interpretation

Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                         ED-AMI Measures
                                                                            Data Elements
Notes for Abstraction             available from the 12-lead ECG performed closest to the
continued:                        time of emergency department arrival, select “No.” Do
                                  not use an interpretation from another ECG performed
                                  that may be available.
                                 Do NOT use ECGs done more than 1 hour prior to
                                  emergency department arrival.
                                 This information must be taken from the interpretation.
                                 An ECG interpretation is defined as:
                                        A 12-lead ECG report in which the name or
                                           initials of the physician/advanced practice
                                           nurse/physician assistant (physician/APN/PA)
                                           who reviewed the ECG is signed, stamped, or
                                           typed on the report, or
                                        Physician/APN/PA notation of ECG findings in
                                           another source (e.g., progress notes).
                                   Interpretations must be taken directly from
                                       documentation of ECG findings. Do not measure ST-
                                       segments or attempt to identify or judge LBBB or ST-
                                       elevation on the ECG tracing.
                                 For ECG reports and physician/APN/PA references to
                                  ECG findings not specified as 12-lead, infer the ECG was
                                  12-lead, unless documentation indicates otherwise.
                                 If the location of an MI is documented and it is described
                                  as acute/evolving, or an acute/evolving MI is described as
                                  “transmural” or “Q wave,” the presumption is being made
                                  that it is an ST-elevation MI.
                                 Do not consider “subendocardial” an MI “location” (e.g.,
                                  “acute subendocardial MI” should be disregarded).
                                 Consider “infarct” synonymous with myocardial
                                  infarction (e.g., “Acute inferior infarct” should be
                                  included.).
                                 MIs MUST be described as acute or evolving (in
                                  addition to documentation of location or description of
                                  MI as “transmural” or “Q wave”). “Evolving” should be
                                  considered synonymous with “acute.”
                                 MIs described in any of the following ways should be
                                  disregarded (neither inclusion nor exclusion):
                                  -Age not addressed (e.g., "inferior MI")
                                  -Age undetermined (e.g., “inferior MI age undetermined,”
                                  “Extensive anterior infarct, age indeterminate”)
                                  -New
                                  -Old
                                  -Previously seen (e.g., “anterolateral MI on or before 09-
                                  01-2004”, “posterior MI seen on ECG two weeks ago")
                                  -Recent
                                  -Subacute
Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                      ED-AMI Measures
                                                                         Data Elements
                                 When both an inclusion and exclusion are documented in
                                  reference to the same ECG, or documentation is
                                  otherwise conflicting, select “No.” Consider
                                  documentation as conflicting




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                        ED-AMI Measures
                                                                           Data Elements
Notes for Abstraction             If there is documentation of both an included term and
continued:                        excluded term (per inclusion/exclusion lists or Notes for
                                  Abstraction) or documentation of an included term with
                                  additional documentation, which clearly contradicts the
                                  inclusion term. Examples:
                                  o Signed ECG report lists “LBBB” and “non Q wave
                                       MI”
                                  o The ER physician/APN/PA reports “ST-elevation” on
                                       the initial ECG, while the attending cardiologist
                                       interprets this same ECG as “No ST-elevation”
                                 If there is documentation of an included term and
                                  documentation of a finding, which is not addressed in the
                                  inclusion/exclusion lists or Notes for Abstraction, this
                                  should NOT be considered conflicting documentation. In
                                  the following examples, “Yes” should be selected:
                                  o Signed ECG report notes “probable lateral injury,”
                                       while the physician/APN/PA’s progress note states
                                       “ST-elevation present”
                                  o Findings of “posterior AMI” and “ST depression” are
                                       noted on the signed ECG report
                                 LBBBs or ST-elevation described as old, chronic, or
                                  previously seen should be disregarded.
                                 If ST-segment elevation, LBBB, or any of the ST-
                                  segment elevation/LBBB inclusion terms is described
                                  using the qualifier “possible,” disregard that finding
                                  (neither inclusion nor exclusion), and use all other
                                  documented ECG findings included in the
                                  interpretation(s) (e.g., “anteroseptal infarct, possible
                                  acute” per signed ECG report, “ST-elevation” per
                                  physician/APN/PA’s progress note - select “Yes”).
                                 Cases where ST-elevation is described in terms NOT
                                  consistent with  1 mm/.10mV in two or more leads
                                  should be excluded through the guidelines below.
                                  REMINDER: Abstractors should NOT measure ST-
                                  segments or attempt to identify ST-elevation and/or
                                  degree of ST-elevation in the different leads.
                                  o If ST-elevation (ST ) is clearly described as confined
                                       to ONE lead, treat as an exclusion and select “No.”
                                       Examples:
                                        “ST  in V1”– select “No.”
                                        “ST-elevation in a lateral lead”– select “No.”
                                        “ST-elevation in V4” and “acute lateral MI” per
                                           physician/APN/PA-signed ECG report – select
                                           “No.”
                                        “ST  in V1” per progress note and “ST-
                                           elevation” per consultation report – select “No.”
Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                        ED-AMI Measures
                                                                           Data Elements
                                       “STE > 1 mm in V3” and "ST changes consistent
                                          with injury" per ED physician/APN/PA report –
                                          select “No.”
                                  o If ST-elevation (ST ) is described as minimal, <
                                      .10mV, < 1 mm, non-diagnostic, or non-specific in
                                      ALL leads noted
Notes for Abstraction                 to have ST-elevation, treat as an exclusion and select
continued:                            “No.” Examples:
                                       “Minimal ST-elevation in V1 – V4” – select
                                          “No.”
                                       “ST  .05mV in anterior leads” – select “No.”
                                       “Minimal ST-elevation in lateral leads” and “acute
                                          lateral MI” per physician/APN/PA-signed ECG
                                          report – select “No.”
                                       “3 mm ST-segment elevation in leads V1-V3 with
                                          minimal ST-elevation in the lateral leads”– select
                                          “YES” (ST-elevation is not minimal in all leads.
                                          Should not be considered a case of conflicting
                                          documentation).
                                  o If ST-elevation (ST ) is described as minimal, <
                                      .10mV, < 1 mm, non-diagnostic, or non-specific in
                                      GENERAL terms, where lead(s) are NOT specified
                                      (e.g., “minimal ST-elevation,” “ST  .5 mm”), infer
                                      this description is referring to ALL leads which have
                                      ST-elevation, and follow the guideline above.
                                      Example: “ST-elevation .05mV” per the
                                      physician/APN/PA-signed ECG and “ST-elevation”
                                      per physician/APN/PA’s progress note – select ”No.”
                                 The term “ST abnormality” should not be considered
                                  synonymous with “ST-elevation.”
                                 Pacing can obscure ST-segment changes. If there is
                                  documentation of both pacemaker/pacing and ST-
                                  elevation/LBBB in the interpretation(s) of the ECG done
                                  closest to arrival, select “No.” Exception: Disregard
                                  pacemaker findings if (1) pacing is described as atrial
                                  only, or (2) documentation suggests the patient has a non-
                                  functioning pacemaker.
Suggested Data                   Ambulance record
Sources:                         Consultation notes
                                 ECG reports
                                 Emergency department record
                                 Progress notes


Guidelines for Abstraction:
Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                       ED-AMI Measures
                                                                          Data Elements
                   Inclusion                                   Exclusion
 ST-segment elevation                           ST-segment elevation
  Myocardial infarction (MI), with any          Non Q wave MI (NQWMI)
    mention of location or combinations of       Non ST-elevation MI (NSTEMI)
    locations (e.g., anterior, apical, basal,    ST  clearly described as confined to
    inferior, lateral, posterior, or               ONE lead
    combination), IF DESCRIBED AS                ST  described as minimal, < .10mV, <
    ACUTE/EVOLVING (e.g., “posterior               1 mm, non-diagnostic, or non-specific in
Guidelines for Abstraction continued:
                   Inclusion                                     Exclusion
    AMI”)                                           ALL leads noted to have ST-elevation
  Q wave AMI                                      ST-elevation clearly described as
  Q wave MI, IF DESCRIBED AS                       confined to ONE lead
    ACUTE/EVOLVING                                 ST-elevation described as minimal, <
  ST                                              .10mV, < 1 mm, non-diagnostic, or non-
  ST abnormality consistent with injury,           specific in ALL leads noted to have ST-
    infarct, or acute/evolving MI                   elevation
  ST changes consistent with injury,              ST-elevation due to early repolarization
    infarct, or acute/evolving MI                  ST-elevation due to left ventricular
  ST consistent with injury, infarct, or           hypertrophy (LVH)
    acute/evolving MI                              ST-elevation due to normal variant
  ST-elevation (STE)                              ST-elevation with mention of
  ST-elevation myocardial infarction               pericarditis
    (STEMI)                                        ST-elevation with mention of
  ST-segment noted as  .10mV                      Printzmetal/Printzmetal's variant
  ST-segment noted as  1 mm                      ST-segment elevation, or any of the
  Transmural AMI                                   other ST-segment elevation inclusion
  Transmural MI, IF DESCRIBED AS                   terms, described using one of the
    ACUTE/EVOLVING                                  negative modifiers or qualifiers listed in
                                                    Appendix H, Table 2.6, Qualifiers and
 Left bundle branch block (LBBB)                    Modifiers Table
  Intraventricular conduction delay of            ST-elevation, or any of the other ST-
    LBBB type                                       segment elevation inclusion terms, with
  Variable LBBB                                    mention of pacemaker/pacing (unless
                                                    atrial only)

                                                Left bundle branch block (LBBB)
                                                 Incomplete left bundle branch block
                                                   (LBBB)
                                                 Intraventricular conduction block
                                                 Intraventricular conduction delay
                                                   (IVCD)
                                                 Left bundle branch block (LBBB), or
                                                   any of the other left bundle branch block
                                                   inclusion terms, described using one of
Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                 ED-AMI Measures
                                                                    Data Elements
                                              the negative modifiers or qualifiers
                                              listed in Appendix H, Table 2.6,
                                              Qualifiers and Modifiers Table
                                             Left bundle branch block (LBBB), or
                                              any of the other left bundle branch block
                                              inclusion terms, with mention of
                                              pacemaker/pacing (unless atrial only)




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                         ED-AMI Measures
                                                                            Data Elements
Data Element Name:              ED Probable AMI

Collected For:                  ED-AMI-1

Definition:                     Documentation a physician/APN/PA presumed the
                                emergency department patient’s condition to be cardiac in
                                origin?

Suggested Data
Collection Question:            Was the emergency department patient’s condition
                                presumed to be cardiac in origin?

Format:                         Length:    1
                                Type:      Alphanumeric
                                Occurs:    1

Allowable Values:               Y (Yes) There was physician/APN/PA documentation a
                                        cardiac condition was being considered for the
                                        emergency department patient.

                                N (No)     There was no physician/APN/PA documentation
                                           or unable to determine if a cardiac condition
                                           was being considered for the emergency
                                           department patient.

Notes for Abstraction:       -A differential/working diagnosis of acute myocardial
                             infarction abstracts as a “Yes”
                             -See inclusion list for documentation of probable AMI.
                             -Documentation must include one of the AMI qualifiers or
                             one of the AMI qualifiers and one of the positive qualifiers

Suggested Data                PHYSICIAN/APN/PA DOCUMENTATION ONLY
Sources:                       Consultation notes
                               Emergency department record
                               Physician orders
                               Physician notes

Guidelines for Abstraction:




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                         ED-AMI Measures
                                                                            Data Elements
                  Inclusion                                          Exclusion
 Acute Myocardial Infarction Qualifier                  Ruled out
 Heart attack                                           Chest Pain
 Myocardial Infarction
 Ischemia
 Cardiac
 Positive Qualifiers
    The following qualifiers should be abstracted as
     positive findings, unless otherwise specified:
    Appears to have
    Consider
    Consistent with (c/w)
    Diagnostic of
    Evidence of
    Indicative of
    Likely
    Most likely
    Probable
    Representative of
    Cannot exclude
    Cannot rule out
    Could be
    Could have been
    May have
    May have had
    May indicate
    Possible
    Questionable (?)
    Risk of
    Rule out (r/o)
    Suggestive of
    Suspect
    Suspicious
    Differential diagnosis
    Working diagnosis
    Versus (vs)
    +




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                            ED-AMI Measures
                                                                               Data Elements




Data Element Name:              ED Reason for Delay in Fibrinolytic Therapy

Collected For:                  ED-AMI-2, ED-AMI-3

Definition:                     Physician/advanced practice nurse/physician assistant
                                (physician/APN/PA) documentation of a reason for a delay
                                in initiating fibrinolytic therapy after patient arrival to
                                emergency department. System reasons for delay are
                                NOT acceptable.

Suggested Data
Collection Question:            Is there physician/APN/PA documentation of a reason for a
                                delay in initiating fibrinolytic therapy after patient arrival to
                                the emergency department?

Format:                         Length:     1
                                Type:       Alphanumeric
                                Occurs:     1

Allowable Values:               Y (Yes) There is physician/APN/PA documentation of a
                                        reason for a delay in initiating fibrinolytic

Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                             ED-AMI Measures
                                                                                Data Elements
                                             therapy after patient arrival to the emergency
                                             department.

                                  N (No)     There is no physician/APN/PA documentation
                                             of a reason for a delay in initiating fibrinolytic
                                             therapy after patient arrival to the emergency
                                             department, or unable to determine from
                                             medical record documentation.


Notes for Abstraction:            System reasons for delay are not acceptable,
                                   regardless of any linkage to the timing of
                                   fibrinolysis/reperfusion.
                                           Equipment-related (e.g., IV pump malfunction)
                                           Staff-related (e.g., waiting for fibrinolytic agent
                                       from pharmacy)
                                           Participation in clinical trial (e.g., waiting for
                                       trials coordinator)
                                           Consultation with other clinician

Notes for Abstraction             The linkage between a non-system reason and the
continued:                         timing/delay of fibrinolysis/reperfusion must be made
                                   clear somewhere in the medical record. Abstractors
                                   should NOT make inferences from documentation of a
                                   sequence of events alone or otherwise attempt to interpret
                                   from documentation. Clinical judgment should not be
                                   used in abstraction.
                                   o Examples of ACCEPTABLE documentation:
                                        “Hold on fibrinolytics. Will do CAT scan to r/o
                                           bleed.”
                                        “Patient waiting for family and clergy to arrive –
                                           wishes to consult with them before thrombolysis.”
                                        “Pt. presented to ER in full cardiac arrest. ACLS
                                           protocol instituted. Unable to begin thrombolytics
                                           until patient stable.”
                                        “Need to control blood pressure before
                                           administering fibrinolysis.”
                                        “He had to be defibrillated several times prior to
                                           starting fibrinolytic therapy.”
                                   o Note: Initial patient/family refusal of
                                       fibrinolysis/reperfusion is an acceptable reason for
                                       delay and does NOT need to be linked to the
                                       timing/delay in fibrinolytic therapy (e.g., “Patient
                                       refusing thrombolysis”).
                                   o Examples of UNACCEPTABLE documentation:
                                        “Patient is discussing thrombolysis with family.”
Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                         ED-AMI Measures
                                                                            Data Elements
                                          (Effect on timing/delay of fibrinolysis not
                                          documented)
                                       “Patient developed v fib and cardiorespiratory
                                          arrest. Defib x 2, intubated. Fibrinolytic therapy
                                          started.” (Linkage to timing/delay of fibrinolysis
                                          not clear – Abstractor should not infer from
                                          sequence of events)
                                       “ST-elevation on initial ECG resolved. Chest pain
                                          now recurring. Begin lytics.” (linkage to
                                          timing/delay of fibrinolysis requires clinical
                                          judgment)
                                       “Fibrinolysis contraindicated – too high risk.”
                                          (Effect on timing/delay of fibrinolysis not
                                          documented)
                                       “Lytic therapy not indicated.” (Effect on
                                          timing/delay of fibrinolysis not documented)
                                 If unable to determine whether a documented reason
                                  is system in nature, or if physician/APN/PA
                                  documentation does not establish a linkage between
                                  event(s)/condition(s) and the timing/delay in
                                  fibrinolysis/reperfusion, select “No.”
                                 Reasons given for not initiating fibrinolytic therapy
                                  sooner after arrival should be collected, regardless of how
                                  soon after arrival it was ultimately initiated or how
                                  minimal the delay.


Suggested Data                PHYSICIAN/APN/PA DOCUMENTATION ONLY
Sources:                       Consultation notes
                               Emergency department record
                               Physician orders
                               Progress notes

Guidelines for Abstraction:
                 Inclusion                                         Exclusion
 None                                             None




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                           ED-AMI Measures
                                                                              Data Elements
Data Element Name:                ED Transfer for Primary PCI

Collected For:                    ED-AMI-5

Definition:                       Documentation the patient was transferred from this
                                  facility’s emergency department to another facility for
                                  primary PCI.

Suggested Data
Collection Question:              Was there documentation the patient was transferred from
                                  this facility’s emergency department to another facility for
                                  primary PCI?

Format:                           Length:    1
                                  Type:      Alphanumeric
                                  Occurs:    1

Allowable Values:                 Y (Yes) There was documentation the patient was
                                          transferred from this facility’s emergency
                                          department to another facility for primary PCI.

                                  N (No)     There was not documentation the patient was
                                             transferred from this facility’s emergency
                                             department to another facility for primary PCI.

Notes for Abstraction:         Documentation must include a specifically defined
                                reason for transfer as “Primary PCI”or “PCI”

Suggested Data                     Any DMAT documentation
Sources:                           Emergency department record
                                   Nursing notes
                                   Physician order
                                   Transfer sheet
                                   Triage note


Guidelines for Abstraction:
                  Inclusion                                           Exclusion
 Transfer for primary PCI                           None
 Transfer for PCI




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures
                                                                           ED-AMI Measures
                                                                              Data Elements
Data Element Name:                 ED Transfer From Another ED

Collected For:                     All ED-AMI Measures

Definition:                        Documentation that patient was received as a transfer from
                                   another hospital emergency department.

Suggested Data
Collection Question:               Was the patient received as a transfer from an emergency
                                   department of another hospital?

Format:                            Length:    1
                                   Type:      Alphanumeric
                                   Occurs:    1

Allowable Values:                  Y (Yes) Patient received as a transfer from another
                                           hospital emergency department.

                                   N (No)     Patient not received as a transfer from another
                                              hospital emergency department or unable to
                                              determine from medical record documentation.

Notes for Abstraction:              The emergency department of another hospital includes
                                     both emergency room AND observation bed/unit stays at
                                     that hospital.
                                    If a patient is transferred in from the emergency
                                     department or observation unit of ANY outside hospital,
                                     select “Yes”, regardless of whether the two hospitals are
                                     close in proximity, part of the same hospital system, have
                                     a shared medical record or provider number, etc.
                                    If a patient is transferred in from a Disaster Medical
                                     Assistance Team (DMAT), which provides emergency
                                     medical assistance following a catastrophic disaster or
                                     other major emergency, select “Yes.”

Suggested Data                     Any DMAT documentation
Sources:                           Emergency department record
                                   Progress notes
                                   Transfer sheet
Guidelines for Abstraction:
                 Inclusion                                            Exclusion
 None                                               None




Oklahoma Foundation for Medical Quality
Hospital Quality Measures Special Study
ED-AMI Measures

								
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