When a diagnosis of ST segment elevation myocardial infarction (STEMI) has been established or is suspected, the most important treatment is quick reperfusion of the occluded blood vessel. Primary percutaneous coronary intervention (pPCI) is the preferred revascularization method for patients with STEMI (1, 2); a pharmacoinvasive strategy is recommended for patients where a timely pPCI is not feasible (3, 4). Timely reperfusion requires timely diagnosis, transport, and treatment, but the timeliness of the intervention is measured in minutes, not hours or days. A well-organized network of primary percutaneous coronary intervention is of paramount importance in providing optimal healthcare for patients in the acute phase of myocardial infarction. Guidelines for treating patients with STEMI (1, 2) stress the importance of organizing a pPCI network between hospitals and emergency medical services that takes into account the specifics of the region, but also includes continuous control of the quality of the system. Professional organizations exist both in Europe (Stent for Life Initiative) (5) and in the USA (Mission: Lifeline®; The Door-to-Balloon Alliance) (6-8) that work on the implementation of programs designed to improve pPCI networks with the goal of achieving timely pPCI interventions.

The invasive cardiologic laboratory in the Slavonski Brod General Hospital in Slavonia was opened in 2003. Even at its conception, we envisaged a regional center that would eventually organize a network for the treatment of patients with ACS, a network which would make pPCI treatment available to every patient with acute myocardial infarction (AMI) in western Slavonia. Due to insufficient numbers of invasive cardiologists on hire, pPCI treatment started being performed only in 2010 and even then only during working hours. On January 1, 2014, our laboratory with 24-hour readiness was introduced into the Croatian pPCI network (9). Approximately 140 pPCI procedures are performed annually in the laboratory, as well as a comparable number of interventions with non-ST elevation acute coronary syndrome (NSTE-ACS). (10) The goal of improving organization is to achieve the aims set out by the Stent for Life initiative of the European Society of Cardiology (5): performing more than 600 pPCI per million inhabitants or using pPCI to treat more than 70% patients with STEMI. We also want to increase the number of pPCI performed to over 180 annually and make timely invasive diagnostics and percutaneous coronary intervention (PCI) available to all patients with NSTE-ACS.

Organizing a pPCI network is a lengthy and logistically complex task demanding a dedicated interdisciplinary team. Such a team is comprised of physicians, nurses, and technicians in emergency medicine (EM) teams, merged emergency hospital admissions (MEHA) in Požega, Nova Gradiška, Pakrac, and Slavonski Brod, and the cardiologic departments of these hospitals along with the intervention team of the laboratory in the Slavonski Brod General Hospital. This interdisciplinary team is dedicated to the expressly stated goal of improving the treatment of patients with ACS in the region, through cooperation and mutual respect, dedication, and tenaciousness in the pursuit of this goal. Better organization will allow us to monitor our own work as well as the efficacy of the system, analyze data and both successes and failures, identify problems, and find avenues of improvement.

To attain these goals, it is necessary to develop a comprehensive and standardized diagnosis, treatment, and destination protocol for the whole region, while also developing an official program of quality monitoring for treatment of patients with ACS.

The most important and basic task is to clearly define a team-based approach and create a comprehensive and standardized diagnosis, treatment, and destination protocol for the whole region, based on current guidelines set by modern medicine (1, 2) that also takes into account the specific characteristics of the region. These joint protocols must clearly define “geographical areas of responsibility” and implement and encourage all measures proven to reduce delays in providing timely reperfusion. (11, 12) These measures include:

In creating these protocols, our goal was to cover all entry-points for patients with ACS into the system, and create protocols that would function as diagnostic and treatment guidelines that would be simple to fulfill, but would at the same time be a source of as much data on the functioning the system as possible. We formed protocols from physicians in EM and MEHA ambulances, protocols for choosing reperfusion treatments for physicians in non-PCI hospitals, and a general statistical sheet that follows the patient from their entry to the system to their discharge from the hospital. The protocols can be found in the Appendix (online, only in Croatian).

The goal of this program is to bring the treatment quality for these patients as close as possible to the ideal level of care they should receive. Such a program must be comprehensive and include not only patients that received an intervention, but also those that were diagnosed with ACS but were not treated with any form of reperfusion – the program should provide the total number of patients with ACS and the number of cases where reperfusion was indicated but not performed (eligible-untreated patients). In creating this program, we aimed to measure and monitor all aspects of belated treatment, i.e. the timeframes of timely reperfusion, at all levels of patients care from entry to the system to the final angiogram, as well as measure quality and comprehensiveness indicators in the treatment of patients with ACS.

For EM services:

For MEHA:

Adding up the above time gives the door-in to door-out (DIDO) time for hospitals where PCI is unavailable

For the entire network:

The goal of gathering, analyzing, and sharing data on the treatment network for patients with ACS is to improve the system as a whole. Monitoring everyday work performance is necessary to provide insight on the direction we are going in and on what can be improved, whereas getting feedback is a key element in continuous improvement for all the members of the team that participate in patient treatment. Monitoring and analyzing all the above-mentioned data is a momentous task that can only be achieved with the full participation of all members of the team. We hope that our quality monitoring program will be successful in west Slavonia, in which case we hope to set up a national registry of patients with ACS, which would include all interested parties – professional societies, the Ministry of Health, and the Croatian Health Insurance Fund.