Development of Systems of Care for ST-Elevation Myocardial Infarction Patients
Authors: Penelope Solis, Ezra A. Amsterdam, Vincent Bufalino, Barbara J. Drew, Alice K. Jacobs
Journal: Circulation (2007)

T he establishment of timely access to primary percutane- ous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) patients holds great promise for improving quality of care and patient outcomes.As described in other sections of these conference proceedings, there are significant barriers to the establishment of the ideal system.Changes in policy will be required to overcome many of the obstacles that preclude the delivery of optimal care for all STEMI patients.Short-and long-term policy recommendations that can foster an ideal STEMI system environment are described below.These recommendations focus on how to maximize opportunities to improve the care of STEMI patients by enhancing the processes that are currently available but not fully implemented. Short-Term Policy Recommendations Evaluation of Resources for STEMI Systems and Access to Primary PCI by State and by RegionTo ensure that states have the resources available to effectively adopt an ideal system will require that a state or region interested in implementing such a system evaluate their existing resources and analyze how many financial and human resources they would be willing to commit.A state or region should evaluate its emergency medical services (EMS) capabilities and identify the number and location of primary PCI-capable hospitals within a safe distance that would allow for timely treatment of a STEMI patient with primary PCI.It should also assess the total number of STEMI patients that their hospitals receive on an annual basis.This information would help to better identify whether the existing primary PCI hospitals could handle the volume of patients who may be eligible for primary PCI. Evaluation of State Regulations and Pending LegislationAnother factor that should be considered when implementing a STEMI system is how existing state regulations and pending legislation may positively or negatively affect the implementation of a STEMI system.For example, in the state of Arizona, the director of the Arizona Department of Health Services, in consultation with the medical director of EMS, can establish protocols related to the transport of patients based on the patient's condition. 1This type of regulation can help further the implementation of a STEMI system by allowing advocates to work with the EMS director to implement primary PCI protocols for EMS.In contrast, the Illinois Department of Public Health will investigate a hospital in an EMS system that goes on "bypass status" due to overcrowding in the emergency department to determine whether the action was reasonable. 2 If the Department of Public Health determines the action to have been an improper diversion by the hospital, the hospital incurs a fine.In this instance, it would be important to work together with the Department of Public Health to establish the importance of diversion to primary PCI hospitals.Similarly, approximately 50% of states in the United States have certificate-of-need programs that may affect how aThe American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel.Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.The opinions expressed in this manuscript