The highest mortality rate associated with acute coronary syndrome is observed in patients with ST-segment elevation myocardial infarction (STEMI). Quality care in STEMI management depends on timely reperfusion of the ischemic coronary artery. The CODE STEMI program has been developed to reduce delays and serves as a method to improve quality care in patients with STEMI. Our study aimed to investigate the effects of implementing the CODE STEMI program on quality care and hospital marketing strategy. Our research was a descriptive study with mixed evaluation methods. We enrolled 207 patients with STEMI who underwent primary percutaneous coronary intervention from 2015 to 2018. We used quantitative methods by tracking medical records and administrative documents, as well as qualitative methods by observation and in-depth interviews. Statistical analysis was done using Mann-Whitney and chi-square tests. Our study demonstrated reduced door-to-balloon time, total cost, and length of stay of patients with STEMI who were treated with the CODE STEMI program (p <0.001, p <0.001, and p = 0.009, respectively). In addition, there was a likely decrease in major adverse cardiac event incidence and mortality rate after the implementation of CODE STEMI. The hospital and patients expressed their satisfaction with the CODE STEMI program. The program proved to have good efficacy, effectiveness, optimality, acceptability, legitimation, and equity. It also met the marketing mix principles, which included increasing the total number of patients with cardiovascular diseases as well as increasing levels of public trust in STEMI management. In conclusion, the CODE STEMI program has a positive impact on quality care and hospital marketing strategy.
ST-segment elevation myocardial infarction (STEMI) is an acute ischemic condition of the myocardium that causes myocardial injury or necrosis with a high mortality rate. It is recommended to perform primary percutaneous coronary intervention for patients with STEMI within ≤90 minutes of the first medical contact if the patient is admitted to a hospital with a percutaneous coronary intervention facility. , However, in the general hospital setting, this time target is still difficult to achieve because of several reasons, such as a high number of patients in the emergency room (ER) with different degrees of emergency, delayed transfer to the catheterization laboratory, lack of available facilities, the number of health care personnel, and coordination between medical and administrative staff. This delayed reperfusion therapy will negatively affect clinical outcomes, quality care, and patient satisfaction. , Thus, these issues become the basis of the CODE STEMI program implementation. By hastening treatment, starting from the first medical contact to primary percutaneous coronary intervention, it is expected that the CODE STEMI program can improve the quality of care for patients with STEMI based on the Donabedian concept. This research aimed to study the impact of the CODE STEMI program on quality care and marketing hospital strategy in patients with STEMI.
Methods
The study was a mixed study with quantitative and qualitative analysis using the observational method and retrospective cohort design. The study was conducted at the National Central General Hospital Cipto Mangunkusumo Hospital in Jakarta between October 1, 2019, and November 29, 2019. The study included patients with STEMI diagnoses established between January 1, 2015, and December 31, 2018.
Samples were collected using the total sampling method by evaluating data on medical records. A total of 207 patients had fulfilled the inclusion criteria with STEMI diagnosis. The established STEMI diagnosis between 2015 and 2016 was included in the non–CODE STEMI group (72 patients), whereas patients who had diagnoses between 2017 and 2018 were included in the CODE STEMI group (135 patients). By tracing data retrospectively from medical records and administrative documents of the patients, we obtained data of response time (door-to-balloon time) and clinical outcomes (major adverse cardiac events [MACE] and mortality), the total cost during hospitalization, and length of hospital stay ( Figure 1 ). We excluded patients with existing MACE or severe co-morbidities on hospital admission such as acute stroke, hepatic cirrhosis, chronic inflammation, sepsis, autoimmune disease, and malignancy. We also excluded patients whose medical records were incomplete.
Qualitative data were obtained from in-depth interviews ( Figure 1 ). To confirm the validity of the obtained information, the triangulation method of the sources was performed by interviewing 10 informants. Each party was provided with different questions consistent with their field of work. In addition, the questions for patients with STEMI and their families were about the quality of care for STEMI at Cipto Mangunkusumo Hospital. They were also asked about the equity of health care services because there are some negative assumptions about how hospitals discriminate patients according to the health insurance they use (i.e., patients with national health insurance experienced dissatisfaction with the service from health workers who seemed to discriminate against them with patients with pay out-of-pocket or private insurance).
The CODE STEMI program was activated right after the diagnosis was established. The diagnosis of STEMI was established by fulfilling the criteria, including typical chest pain, the change in electrocardiography (new or suspected new ST-segment elevation or new left bundle branch block), and the increase of cardiac enzyme in blood serum (preferably, the elevation of high-sensitivity troponins I or T). Typical chest pain was described as pain, pressure, tightness, and burning sensation or chest pain–equivalent symptoms such as dyspnea, epigastric pain, and pain in the left arm. , The steps of the CODE STEMI program are summarized in Figure 2 , and the differences of management and pathway between non–CODE STEMI and CODE STEMI programs are detailed in Table 1 .
| Non–CODE STEMI | CODE STEMI |
|---|---|
| The administrative process is still the same as ordinary patients so they have to queue and wait a long time for registration | The administration process for patients with CODE STEMI comes first |
| Special tools such as ECG are used for all patients in the ER | One ECG device is provided specifically for CODE STEMI patients |
| STEMI patients must complete payment or insurance procedures before revascularization | Patients with CODE STEMI are immediately treated for revascularization without waiting for the completion of fees or insurance. |
| The basis for the diagnosis is waiting for the results of all the supporting examinations to be completed, including lab and x-ray | The basis for the diagnosis is typical chest pain and a typical ST elevation on the ECG |
| The division of roles between medical and nonmedical staff is not yet clear, so they are often confused about who to contact or who to take the patient to the catheterization room (cath lab). | The division of tasks and the flow of treatment have been arranged in the Clinical Pathway. Patients must arrive at the catheterization room a maximum of 70 minutes after entering the ER |
| The cardiovascular team is difficult to gather | The cardiovascular team must be ready within 15 minutes |
The data were coded and entered into an Excel datasheet and were analyzed using IBM SPSS Statistics for Windows, Version 20.0. (Armonk, New York. IBM Corp. Released 2011). We compared door-to-balloon time, total cost, and length of stay of patients with STEMI before (January 2015 to December 2016) and after (January 2017 to December 2017) the implementation of the CODE STEMI program. Data comparisons were conducted using Mann-Whitney and chi-square tests. This study was approved by the institutional review board of the Faculty of Medicine Universitas Indonesia, and other ongoing efforts to reduce the same outcomes (i.e., door-to-balloon time) were none.
Results
A total of 207 patients were recruited in this study and divided into the CODE STEMI group (135 patients) and the non–CODE STEMI group (72 patients) with detailed characteristics of patients listed in Table 2 . There was a downward trend each year in the mean value of door-to-balloon time after the implementation of the CODE STEMI program (288 [120 to 1,376] minutes vs 158 [66 to 640] minutes, p <0.001). In Figure 3 , we can see that there was a reduced door-to-balloon time in non–CODE STEMI compared with the CODE STEMI group, as much as 130 minutes (45%). Furthermore, we also found a reduced percentage of MACE (including stroke, cardiogenic shock, congestive heart failure, lethal dysrhythmia, and pericarditis) and mortality rate (6 months, 1-year, and 2-year mortality) as much as 10.83% from 35 (48.61%) in the non–CODE STEMI program to 51 (37.78%) in the CODE STEMI program risk ratio 0.777 (95% confidence interval 0.564 to 1.071) and 4% from 6 (8.33%) in non–CODE STEMI program to 6 (4.44%) in the CODE STEMI program risk ratio 0.533 (95% confidence interval 0.178 to 1.593), respectively.
