The present study quantitatively explored associations between the quantity and quality of healthcare professionals at emergency medical stations and the transfer delay and in-hospital mortality of patients with STEMI, and qualitatively analyzed the reasons for the lack of quantity and quality of healthcare professionals at emergency medical stations.
First, our study demonstrated that the density of healthcare professionals was negatively associated with transfer delay for patients with STEMI. In China, each ambulance is usually equipped with a physician, a nurse and a stretcher-bearers17. These professionals are responsible for providing EMS and treatment to patients during the transfer process, and monitoring patients before they are admitted to hospital18. Our findings were consistent with previous studies, which showed that sufficient healthcare professionals are essential for providing basic health services and improving health outcomes19,20. High-quality healthcare professionals are widely recognized as the prerequisite for effective healthcare, and a critical factor that determines healthcare system performance21. Pre-hospital EMS is an integral part of the healthcare system22. In 2009, China initiated a comprehensive healthcare system reform, which included a goal of solving the lack of healthcare professionals. However, Shenzhen, as a first-tier city with a relatively high economic level, still faces a lack of emergency healthcare professionals. Therefore, the quantity of healthcare professionals at emergency medical stations should be increased to ensure the quality of pre-hospital EMS.
Second, we found that a higher density of physicians with undergraduate degrees and a higher density of nurses with college degrees were associated with shorter transfer delay for patients with STEMI. For the emergency medical care of patients with STEMI, healthcare professionals are required to recognize the symptoms immediately, take ECG quickly, and rapidly transmit ECG results to the hospital emergency and cardiology departments, so that the hospital can complete the necessary preparations before patient arrival. This means the patient can bypass the emergency and cardiology departments after arriving at the hospital, and go directly to the catheterization laboratory for rapid treatment, thereby reducing transfer delay and in-hospital delay23. The wrong decision by healthcare professionals that results in the patient not being sent to the catheterization laboratory in a timely manner can endanger the patient’s health and even lead to death24,25. The professional competence of healthcare professionals is crucial in pre-hospital emergency medical care. A previous study showed that competent healthcare professionals are essential for providing healthcare services and determine the degree to which the services meet healthcare demand26. A higher education level and participation in education programs can also improve competence among healthcare professionals27. Therefore, the quality of healthcare professionals and the quality of healthcare services can be improved through on-the-job training for healthcare professionals, and skills in emergency medicine should be cultivated through appropriate medical education and skills training.
Third, although the quantity and quality of healthcare professionals are directly associated with transfer delay, they did not influence in-hospital mortality of patients with STEMI for multiple reasons. For example, the allocation of healthcare professionals at emergency medical stations mainly affects transfer delay, which accounts for approximately 25% of the total delay; in-hospital delay also affects treatment time and further influences in-hospital mortality. In addition, many factors influence the mortality of patients with STEMI, such as basic demographic characteristics28, medical history29, and delay caused by patient-level factors30.
Fourth, our qualitative analysis revealed that the workload of these healthcare professionals was not proportional to their income, meaning incentive mechanisms failed to promote their motivation to work. The equalization of basic public health services (EBPH) policy implemented in 2009 expanded the coverage of public health services in China, and governments at all levels allocated funds for these services. However, the EBPH policy indicates special funds can only be used to support operating costs such as medical resource consumption and transportation, and cannot compensate for personnel expenses. Therefore, the input of healthcare professionals and the corresponding increase in workload do not receive sufficient rewards. The explanation for this phenomenon was consistent with previous studies; that is, healthcare workers are unwilling to provide medical services because they are concerned about the rapid increase in workload without corresponding financial returns31–33. Furthermore, the performance of emergency medical stations is only evaluated by the number of ambulances dispatched, and not the quality of treatment. Thus, healthcare professionals may be motivated to drive the ambulances out, but not to provide treatment. There is also a growing trend not to transport patients in many Western European countries34,35. In addition, there are complex and multifactorial factors affecting the motivation for healthcare professionals in an ambulance not to treat patients. This decision is influenced by healthcare professionals, patients and their relatives, the healthcare system (referral or general physician), and auxiliary tools, such as a patient’s refusal to accept therapy, disease severity of the patient, and the ability of healthcare professionals28,36, which results in prolonged transfer time. Therefore, the performance of emergency medical stations should be linked to service quality. As well as covering in-hospital mortality, service quality but should also cover clinical pathways, such as whether the healthcare professionals on the ambulance identified patient symptoms correctly, completed an ECG immediately, and transmitted the ECG results to the hospital emergency and cardiology departments in a timely manner.