The Chest Pain MI Registry Case Scenario for June of 2022 will review Part 1 of Going Beyond the Obvious in Metric Review. This is a two-part series, and the second part will be presented in the July case scenario. A 41-year-old male presents to the emergency department at 11 a.m. with complaints of shortness of breath, headache, mild chest pressure, and a toothache. He has a history of heavy smoking and daily alcohol use. He admits to no medical care in the past 10 years and does not have a primary care physician. The initial and second ECG are negative for STEMI, and the troponin values are below the 99th percentile upper reference limit. The ED physician proceeds to explain the plan of care based on the hospital's chest pain protocol. The patient refused to proceed with the recommended plan of care and left against medical advice. At 4.25 p.m., the patient returns to the emergency department with the same symptoms. The first ECG obtained during the second ED visit is positive for STEMI with ST elevations greater than 3 millimeters in four contiguous leads, V3, V4, V5, and V6, signifying an anterolateral MI. The cath lab staff is activated, and the patient receives a drug-eluting stent to the distal portion of the LED. The first visit to the emergency department is not included in the registry as this facility abstracts NSTEMI and STEMI patient types only, and inclusion criteria are not met. The second patient visit is entered into the chest pain of my registry as the patient met both the inclusion criteria and the patient type definition for STEMI pre-admit. The following ECGs are entered into the ACC online data collection tool per the Data Dictionary's coding instructions and target value of any occurrence between 24 hours prior to first medical contact and discharge. Our first question, is the patient included in the numerator for metric 37, first medical contact and device time? Number one, no, or number two, yes. And the answer is yes. This patient is included in numerator of metric 37, first medical contact and device time. Let us see the outcome of this patient scenario in metric 37. The data abstractor evaluates the data on Monday morning after a green submission status was achieved in the DQR on the prior Thursday. She expected to see the patient met the numerator as yes with first medical contact to device time of 82 minutes, which is well above the average length of time at her facility for STEMI patients who arrived by private vehicle. She and her facility are engaged in quality care. She had planned to present this to the quality committee and highlight the prolonged arrival to device time of 82 minutes for a STEMI patient who presented with classic ACS symptoms. However, metric 37, first medical contact and device time displays a result of 40 minutes. She emails NCDR to make them aware of the discrepancy. Please review the scenario and the second question. Is metric 37, first medical contact to device time functioning as expected? Number one, no, or number two, yes. The answer is number two, yes. Metric 37 algorithms are functioning as expected. When there is a negative ECG followed by a positive ECG, the algorithms will evaluate the patient's time to device based on the date and time of the STEMI, STEMI equivalent ECG. The initial ECGs obtained prior to the patient leaving against medical advice met the target value of sequence number 12286, electrocardiogram counter, and were abstracted appropriately. The algorithms are complex and sensitive. However, they're not able to accommodate rare scenarios such as the one provided here. It is in the facility's best interest to evaluate all metric and detail line results of all patients regardless of numerator criteria. The facility evaluated the results of metric 37 based on compliance with their facilities protocols and process improvement initiatives. This facility's goal is to have a door to balloon time of less than 60 minutes. Thank you for viewing the Chest Panami Registries June 2022 Part 1 case scenario. Please stay tuned and see how this discussion with the abstractor and NCDR progresses.

STEMI

emergency department

cath lab

door to balloon time

positive ECG