Ami Cases Eligible for Primary Pci

HISTORICAL UTILIZATION REPORT

AMI CASES ELIGIBLE FOR PRIMARY PCI

Michigan Department of Health & Human Services

CERTIFICATE OF NEED

Authority: PA 368 of 1978, as amended
Completion: Is voluntary, but is required to obtain a Certificate of Need. If NOT completed, a Certificate of Need will NOT be issued. / The Department of Health & Human Services is an equal opportunity employer, services and programs provider.

INSTRUCTIONS:

1.Provide actual data for the most recent 12-month period available prior to the date an application is submitted to the department (2 copies plus original). All supporting documentation must be reviewed and verified by the applicant’s chief cardiologist or cardiac catheterization laboratory director (please provide a signed letter verifying review of each reference case).

2.The “DHHS No.” assigned number in column 1 for each reference case must be clearly identified in the upper right hand corner of each supporting document (i.e., EKG, blood study, etc.).

3.The “Hospital Identifier” in column 2 is to be used by the reporting facility as an audit trail. The identifier shall not reveal patient specific information (i.e., social security number).

4.The “Service Date” in column 3 should indicate the date the diagnosis for AMI was made.

5.The “STEMI” in column 4 should indicate “+” if the patient demonstrated acute ST-segment elevation MI on EKG.

6.The “Peak CKMB” in column 5 should indicate the blood study level.

7.See Key at bottom of Utilization Report for completion of all other columns.

Notes:

• Supporting documentation must be provided for each reference case identified in the Utilization Report. Documentation must include acute/confirmatory EKG and blood study (Peak CKMB) resulting in the diagnosis along with treatment or transfer reports (i.e., lytic order, ambulance release).
• All patient identifiers on supporting documentation, such as EKGs and blood studies, must be removed/blocked out.
• Acute EKGs and blood studies must demonstrate that the patient was seen in the emergency department with a reference date, which must correspond with the Service Date on the Utilization Report.

CERTIFICATE OF NEED REVIEW STANDARDS FOR CARDIAC CATHETERIZATION SERVICES

Section 3. Requirements to initiate cardiac catheterization services -- applicants for an adult diagnostic cardiac catheterization service with provision to perform primary PCI for patients experiencing AMI (ST elevationor new left bundle branch block) without on-site open heart surgery services. Sec.3.(4) An applicant shall project a minimum of 36 primary pcicases based on data fromthe most recent 12-month period, preceding the date the application was submitted to the Department. Primary PCI volume shall be projected by documenting, as outlined in Section 11, and certifying that the applicant treated or transferred enough ST segment elevation AMI cases during the most recent 12 months preceding the date the application was submitted to the Department to maintain 36 primary pci cases annually. Factors that may be considered in projecting primary pci volume are the number of thrombolytic eligible patients per year seen in the Emergency Department (as documented through hospital pharmacy records showing the number of doses of thrombolytic therapy ordered for ami in the Emergency Department) and/or documentation of emergency transfers to an open heart surgery facility for primary pci.

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CON-210-C (04-15)

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HISTORICAL UTILIZATION REPORT

Facility Name:
(Hospital) / CON
Application No.: / Reporting Period (most recent 12-month): to / Date
Submitted:
DHHS No. / Hospital Identifier / Service Date / STEMI1 / Peak CKMB / Location of Infarct2 / Treatment3 / Disposition of Patient4 / DCH Use Only
(Confirmed)
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1. STEMI: (+) indicates acute ST-segment elevation MI on EKG
2. Location of Infarct: May include inferior, anterior, lateral, posterior, LBBB
3. Treatment: Choose lytic, PCI, or neither
4. Disposition of Patient: Transfer out for PCI, admit for CCU care

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CON-210-C (04-15)

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