Cardiology/original research
Hospital Collaboration With Emergency Medical Services in the Care of Patients With Acute Myocardial Infarction: Perspectives From Key Hospital Staff

Presented as a poster at the American Heart Association Quality of Care and Outcomes Research Scientific Session, May 2012, Atlanta, GA.
https://doi.org/10.1016/j.annemergmed.2012.10.009Get rights and content

Study objective

Evidence suggests that active collaboration between hospitals and emergency medical services (EMS) is significantly associated with lower acute myocardial infarction mortality rates; however, the nature of such collaborations is not well understood. We seek to characterize views of key hospital staff about collaboration with EMS in the care of patients hospitalized with acute myocardial infarction.

Methods

We performed an exploratory analysis of qualitative data previously collected from site visits and detailed interviews with 11 US hospitals that ranked in the top or bottom 5% of performance on 30-day risk-standardized acute myocardial infarction mortality rates, using Centers for Medicare & Medicaid Services data from 2005 to 2007. We selected all codes from the previous analysis in which EMS was most likely to have been discussed. A multidisciplinary team analyzed the data with the constant comparative method to generate recurrent themes.

Results

Both higher- and lower-performing hospitals reported that EMS is critical to the provision of timely care for patients with acute myocardial infarction. However, close collaborative relationships with EMS were more apparent in the higher-performing hospitals, which demonstrated specific investment in and attention to EMS through respect for EMS as valued professionals and colleagues, strong communication and coordination with EMS and active engagement of EMS in hospital acute myocardial infarction quality improvement efforts.

Conclusion

Hospital staff from higher-performing hospitals described broad, multifaceted strategies to support collaboration with EMS in providing acute myocardial infarction care. The association of these strategies with hospital performance should be tested quantitatively in a larger representative study.

Introduction

Emergency medical services (EMS) are a key component of the emergency cardiovascular care chain of survival.1 Hospitals are increasingly working with EMS agencies to form regional systems to provide timely access to percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction (STEMI).2 The initial focus of hospital-EMS collaboration has been on operational logistics, such as EMS performance of 12-lead ECGs and EMS selection and notification of the appropriate receiving center. Recent evidence indicates that more active collaboration between hospitals and their EMS systems is associated with better performance in acute myocardial infarction care.3, 4 However, the nature of such collaboration is not well understood, and hence there is little guidance for hospitals seeking to improve acute myocardial infarction performance by developing strong working relationships with EMS agencies.

Cardiovascular disease is the most common cause of death in the United States. Variability in risk-standardized mortality rates for patients hospitalized with acute myocardial infarction between US hospitals has been well established, even after adjusting for severity of illness.5 Studies have identified hospital characteristics associated with risk-standardized mortality rates, including hospital acute myocardial infarction volume, geographic location, teaching status, and safety net status6, 7; however, these features are not amenable to change. Recent evidence that active collaboration between EMS and clinicians caring for patients with acute myocardial infarction is significantly associated with lower risk-standardized mortality rates is an actionable opportunity for hospitals to improve their care for patients hospitalized with acute myocardial infarction.3

We used a qualitative approach well suited for characterizing complex work processes and organizational dynamics8, 9 to explore hospital staff views on the nature of collaboration between hospitals and EMS in the care of patients hospitalized with acute myocardial infarction and to generate hypotheses for further study.

Section snippets

Study Design

The present study reports findings from a secondary analysis drawing on data from the qualitative component of the Survival After Acute Myocardial Infarction project, a mixed-methods, positive-deviance10, 11 study to identify hospital factors associated with lower 30-day risk-standardized mortality rates.11 The project used a sequential exploratory design12; the first component was a qualitative study using site visits and detailed interviews with 11 hospitals at the extreme ends of the range

Characteristics of Study Subjects

The sample consisted of hospitals diverse with regard to risk-standardized mortality rate, geographic location, hospital size, patient socioeconomic status, and teaching status (Table 1). Interview participants (n=85) who discussed the role of EMS in acute myocardial infarction care included representatives from cardiology, emergency medicine, and hospital leadership (Table 2).

Main Results

Four themes characterized hospital views on EMS-hospital collaborations in the care of patients with acute myocardial

Limitations

We used established approaches to enhance the rigor of our findings8, 17, 23, 24; however, the study has several limitations. First, our findings cannot be generalized to all hospitals and EMS agencies. Findings from qualitative studies are not intended to be generalized, but rather to provide insights into areas that have been previously unexplored and to generate hypotheses for future quantitative evaluation.8 The specific strategies we identified to improve hospital-EMS communication and

Discussion

Hospital-EMS active collaboration is a key strategy in achieving lower risk-standardized mortality rates for patients with acute myocardial infarction.3 In this exploratory study, we sought to characterize key hospital staff perspectives on such collaboration and found that higher-performing hospitals maintained a high level of respect for EMS as valued professionals and colleagues in the overall care of patients with acute myocardial infarction, invested in strong communication and

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    Supervising editor: Judd E. Hollander, MD.

    Author contributions: ABL and LAC conceived the study. All authors acquired the data. ABL, ESS, EJC, and LAC performed the data analysis and interpretation. ABL and LAC drafted the article, and all authors contributed substantially to its revision. ABL had full access to all of the data in the study and takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). This study was funded by the Agency for Healthcare Research and Quality (R01-HS-016929), United Health Foundation, and the Commonwealth Fund (20090565). Dr. Krumholz is supported by grant U01 HL105270-02 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute. Drs. Landman and Spatz were participants in the Robert Wood Johnson Foundation Clinical Scholars Program funded by the Robert Wood Johnson Foundation and the US Department of Veterans Affairs when this study was conducted. Dr. Krumholz reports receiving a research grant from Medtronic, Inc. through Yale University and is chair of a cardiac scientific advisory board for UnitedHealth.

    Publication date: Available online November 7, 2012.

    Please see page 186 for the Editor's Capsule Summary of this article.

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