Development of Systems of Care for ST-Elevation Myocardial Infarction Patients
Authors: Eric D. Peterson, E. Magnus Ohman, Ralph G. Brindis, David J. Cohen, David J. Magid
Journal: Circulation (2007)

T he establishment of systems to improve the quality of care for ST-elevation myocardial infarction (STEMI) patients holds great promise to facilitate patients' access to evidence-based, timely cardiac therapies and, ultimately, to improve patient outcomes.Any evaluation of the quality of STEMI care should be focused squarely on the patient, from initial symptom onset to rapid access to reperfusion therapy and through a coordinated hospital discharge and return to the community.Ideal care therefore requires close collaboration of multiple parties, including the patient, emergency medical services (EMS), emergency physicians, interventional teams, cardiologists, and community-based clinicians.As with any care system, however, attempts to improve the process may not be implemented successfully or, worse, may lead to unintended adverse consequences.As such, it is important to carefully monitor the impact of any new care strategies on clinical outcomes. Conceptual Model for EvaluationThe overall goal of a proposed STEMI system redesign is to improve quality of care and thereby improve patient outcomes.As defined by the Institute of Medicine, STEMI care should be timely, effective, safe, equitable, patient-centered, and cost-effective. 1Although there are many approaches to guide evaluation of care, Donabedian's classic triad of structure-process-outcome provides an ideal model. 2 This identifies the major domains of health care and defines the programmatic features needed to achieve success. StructureStructure refers to component personnel, equipment, and facilities needed to provide ideal STEMI care.At this conference, several model systems provided examples of EMS, emergency department, percutaneous coronary intervention (PCI)-capable hospital, and regional network features associated with improved reperfusion times (Table 1).Although "structure often drives function," these structural features should be used only as a guide and will often need to be individualized for a particular care setting.Many of these features are described elsewhere in this report, yet 2 require further explanation.First, we believe that providers should participate in national data collection and quality improvement programs.Examples of such programs include those for EMS, 3 myocardial infarction, [4][5][6] Participation in such programs provides caregivers with standardized tools for data collection and risk adjustment, as well as feedback on how their care compares with peers.Such feedback systems are known to be a critical element in continuous quality improvement. 8s regional STEMI care delivery systems mature, the model of an individual hospital-centered quality improvement program will need to expand to that of collaborative, community-wide oversight programs.These may include a regional STEMI steering committee and, potentially, a separate data safety monitoring board.Such oversight should have comprehensive representation that includes the region's EMS director and EMS medical director, other emergency services leaders (fire and police), representatives from both the STEMI referral and STEMI-receiving hospitals, and regionalThe 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