title: System dynamics modeling in the evaluation of delays of care in ST-segment elevation myocardial infarction patients within a tiered health system.
abstract: BACKGROUND
  Mortality rates amongst ST segment elevation myocardial infarction (STEMI) patients remain high, especially in developing countries. The aim of this study was to evaluate the factors related with delays in the treatment of STEMI patients to support a strategic plan toward structural and personnel modifications in a primary hospital aligning its process with international guidelines.
  
  
  RESULTS
  The study was conducted in a primary hospital localized in Foz do Iguaçu, Brazil. We utilized a qualitative and quantitative integrated analysis including on-site observations, interviews, medical records analysis, Qualitative Comparative Analysis (QCA) and System Dynamics Modeling (SD). Main cause of delays were categorized into three themes: a) professional, b) equipment and c) transportation logistics. QCA analysis confirmed four main stages of delay to STEMI patient's care in relation to the 'Door-in-Door-out' time at the primary hospital. These stages and their average delays in minutes were: a) First Medical Contact (From Door-In to the first contact with the nurse and/or physician): 7 minutes; b) Electrocardiogram acquisition and review by a physician: 28 minutes; c) ECG transmission and Percutaneous Coronary Intervention Center team feedback time: 76 minutes; and d) Patient's Transfer Waiting Time: 78 minutes. SD baseline model confirmed the system's behavior with all occurring delays and the need of improvements. Moreover, after model validation and sensitivity analysis, results suggested that an overall improvement of 40% to 50% in each of these identified stages would reduce the delay.
  
  
  CONCLUSIONS
  This evaluation suggests that investment in health personnel training, diminution of bureaucracy, and management of guidelines might lead to important improvements decreasing the delay of STEMI patients' care. In addition, this work provides evidence that SD modeling may highlight areas where health system managers can implement and evaluate the necessary changes in order to improve the process of care.
authors: Department of Health Sciences, State University of Maringa, Maringa, Parana, Brazil; Department of Nursing, State University of the West of Parana, Foz do Iguaçu, Parana, Brazil.
authors: Luciano
authors: L
authors: de Andrade
authors: Division of Emergency Medicine, Department of Surgery, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.
authors: Catherine
authors: C
authors: Lynch
authors: Nucleus of Data Processing, State University of Maringa, Maringa, Parana, Brazil; Graduate Program in Informatics - PPGIA, Knowledge Discovery and Machine Learning Group, Pontificia Universidade Católica - PUC-PR, Curitiba, Parana, Brazil.
authors: Elias
authors: E
authors: Carvalho
authors: Instituto de Cardiologia do Rio Grande do Sul - Fundação Universitária de Cardiologia, Porto Alegre, Rio Grande do Sul, Brazil.
authors: Clarissa Garcia
authors: CG
authors: Rodrigues
authors: Department of Medicine, Faculdade Ingá, Maringa, Parana, Brazil.
authors: João Ricardo Nickenig
authors: JR
authors: Vissoci
authors: Department of Informatics, Brasilia University, Brasilia, Brazil.
authors: Guttenberg Ferreira
authors: GF
authors: Passos
authors: Department of Surgery, Duke University Health System, Durham, North Carolina, United States of America.
authors: Ricardo
authors: R
authors: Pietrobon
authors: Department of Nursing, State University of the West of Parana, Foz do Iguaçu, Parana, Brazil.
authors: Oscar Kenji
authors: OK
authors: Nihei
authors: Department of Health Sciences, State University of Maringa, Maringa, Parana, Brazil.
authors: Maria Dalva
authors: MD
authors: de Barros Carvalho
mesh_terms: D001938:Brazil; D003695:Delivery of Health Care / Q000458:organization & administration*; D004562:Electrocardiography; D006801:Humans; D017146:Models, Organizational; D009203:Myocardial Infarction / Q000503:physiopathology / Q000628:therapy*; D013996:Time and Motion Studies