Thank you for viewing the Chest Pain MI Registry's September case scenario regarding sequence number 12447, STEMI type. A 59-year-old female with a past medical history of cervical degenerative disc disease in C5 through C6, hypertension, diabetes mellitus, and obesity presents to the emergency department with neck and arm pain. The ED is at a high census, and the triage RN performs the initial assessment. During the initial assessment, the patient admits she has experienced pain in her neck many times before due to degenerative disc disease. However, the arm pain is new. The RN assesses the patient for neurological deficits, including balance and muscle performance of the upper extremities. No deficits are found. The patient is asked to wait until an ED room becomes available. An hour and a half later, the patient is taken to an exam room. The neck and arm pain remains at a 6 out of 10 on the pain scale. The ED physician orders Rainbow Labs and an ECG. The ECG reveals ST elevation of 2.5 millimeters and leads V1 through V4 with a rate of 75 beats per minute and a troponin I value of 14.2 nanograms per liter. The cath lab team is activated, and the patient is taken to the cath lab for primary PCI for acute STEMI of the LAD. Our question is, the patient presented with neck and arm pain and no chest pain. Per the inclusion criteria document, the patient is included. What is coded for sequence 12247, STEMI type? Is it number one, STEMI pre-admit, or number two, STEMI in-hospital? Please take a few moments to review the scenario and the question. And the answer is number one, STEMI pre-admit. Let us see why this patient is not an in-hospital STEMI, but rather a pre-admit STEMI as the patient presented for symptoms suggested of degenerative disc disease. When determining the STEMI type, the line in the sand is the admission orders. When there are no admission orders written, cardiac or non-cardiac, prior to the diagnostic ECG for STEMI, then pre-admit is selected in sequence 12447, STEMI type. When the ECG positive for STEMI is after admission orders are written for a cardiac or non-cardiac diagnosis, then in-hospital STEMI is selected in sequence 12447, STEMI type. Now let us look at metric 37. This scenario illustrates the numerator for metric 37, first medical contact to device is not met. The first medical contact to device time is greater than 90 minutes with the first ECG obtained greater than 90 minutes after arrival. The patient presented for symptoms consistent with degenerative disc disease. However, these symptoms are also consistent with acute coronary syndrome. This was a big miss and prompted a root cause analysis as valuable myocardium had been lost. The facility decided to post the symptoms of ACS to their ED triage room. Symptoms of ACS can include chest pain, which includes pressure, tightness, and burning, shortness of breath or dyspnea, radiating pain to any area above the navel, GI upset, including indigestion, nausea, and vomiting. It can be difficult to detect ACS symptoms in the older adult population, females, and patients with diabetes mellitus and symptoms can be as vague as presenting for new onset of weakness. Performing an ECG for patients who have pain anywhere from the groin up could save a life. Thank you for viewing the Chest Pain in My Registry's September 2021 case scenario.

cervical degenerative disc disease

emergency department

STEMI pre-admit category

acute coronary syndrome

performing ECGs