We must then be certain EMS has the tools and training to respond appropriately. For example, the AHA (in collaboration with EMS and EM organizations) has conducted an EMS/EM survey encompassing all 50 states to gain a better understanding of existing EMS/EM systems and availability of resources across the country and how best to support and augment these systems.

Just as EMS is being promoted as the new frontier of STEMI diagnosis, the ED must respond to our role as arbiters and real-time coordinators of our nation’s emerging STEMI systems of care. Development of such systems must be a joint effort of multiple contributors. Once in place, however, day-to-day oversight and adjustment of such systems (often on a case-by-case basis) is most easily directed from the ED.

Indeed, it appears that AHA has clearly recognized (and taken to heart) a crucial fact: The key to success (or failure) in improving STEMI care in this country (or any other) is an appreciation for the differing (but equal) contributions of emergency physicians, EMS personnel, and cardiologists to the STEMI continuum of care.

The word “regionalization” often brings to mind uncomfortable associations with perceptions of inefficiency and inflexibility that often accompany large-scale efforts at standardization and regulation. EM and EMS are particularly sensitive to the perceptions of excessive “top down” regulation and oversight, no matter how well intentioned.

For STEMI care, however, regionalization implies something positive: a concerted effort to improve and link existing systems of care, not necessarily creating new and competing models. This optimization can occur at all levels of STEMI systems. For example, on a conceptual level, the smallest functional STEMI system can be viewed in terms of just three components that each facility must work to optimize:

1. STEMI patients who present “at the front door” of an institution.
2. STEMI patients brought to that institution from the field via EMS (encouraged).
3. STEMI patients transferred to or from another institution (encouraged).

Intuitively (from the facility’s perspective), maximal improvement in the quality of local STEMI care could thereby be accomplished by optimizing as few as three key processes:

1. Standardizing the institution’s “in house” STEMI treatment processes.
2. Optimizing the institution’s EMS linkages.
3. Streamlining transfers of STEMI patients to or from that institution.

Application of the “Pareto² principle” or “80/20 rule” to this process has important implications. Identifying the sources of error or delay within each individual STEMI system and then prioritizing efforts to find precise solutions are important for efficient attainment of success.