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Integration of Pre-Hospital Electrocardiograms and ST-Elevation Myocardial Infarction Receiving Center (SRC) Networks

Impact on Door-to-Balloon Times Across 10 Independent Regions

Ivan C. Rokos, MD^_*,_*, William J. French, MD, William J. Koenig, MD, Samuel J. Stratton, MD, MPH, Beverly Nighswonger, RN, Brian Strunk, MD^||, Jackie Jewell, RN^||, Ehtisham Mahmud, MD^¶, James V. Dunford, MD^¶, Jon Hokanson, MD^#, Stephen W. Smith, MD^_**, Kenneth W. Baran, MD, Robert Swor, DO, Aaron Berman, MD, B. Hadley Wilson, MD, Akinyele O. Aluko, MD^||||, Brian W. Gross, MD^¶¶, Paul S. Rostykus, MD, MPH^##, Angelo Salvucci, MD^_***, Vishva Dev, MD, Bryan McNally, MD, MPH, Steven V. Manoukian, MD, Spencer B. King, III, MD^||||||

^_* UCLA-Olive View Medical Center, Sylmar, California
Harbor-UCLA Medical Center, Torrance, California
Los Angeles County EMS Agency, Los Angeles, California
Orange County Health Care Agency, Santa Ana, California
^|| Marin General Hospital, Greenbrae, California
^¶ University of California San Diego, San Diego, California
^# Abbott Northwestern Hospital, Minneapolis, Minnesota
^_** Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota
United Hospital, St. Paul, Minnesota
Beaumont Hospital, Royal Oak, Michigan
Carolinas Medical Center, Charlotte, North Carolina
^|||| Presbyterian Hospital, Charlotte, North Carolina
^¶¶ Heart Clinic of Southern Oregon, Medford, Oregon
^## Jackson County EMS Agency, Ashland, Oregon
^_*** Ventura County EMS Agency, Ventura, California
Los Robles Medical Center, Thousand Oaks, California
Emory University School of Medicine, Atlanta, Georgia
Sarah Cannon Research Institute, Nashville, Tennessee
^|||||| Saint Joseph's Hospital, Atlanta, Georgia

^_* Reprint requests and correspondence: Dr. Ivan C. Rokos, Staff, Northridge Hospital, Assistant Clinical Professor of Medicine, Geffen School of Medicine at UCLA, UCLA-Olive View Medical Center, Department of Emergency Medicine, North Annex, 14445 Olive View Drive, Sylmar, California 91342-1495 (Email: irokos{at}earthlink.net).

Objectives: The aim of this study was to evaluate the rate of timely reperfusion for ST-elevation myocardial infarction (STEMI) with primary percutaneous coronary intervention (PPCI) in regional STEMI Receiving Center (SRC) networks.

Background: The American College of Cardiology Door-to-Balloon (D2B) Alliance target is a >75% rate of D2B 90 min. Independent initiatives nationwide have organized regional SRC networks that coordinate universal access to 9-1-1 with the pre-hospital electrocardiogram (PH-ECG) diagnosis of STEMI and immediate transport to a SRC (designated PPCI-capable hospital).

Methods: A pooled analysis of 10 independent, prospective, observational registries involving 72 hospitals was performed. Data were collected on all consecutive patients with a PH-ECG diagnosis of STEMI. The D2B and emergency medical services (EMS)-to-balloon (E2B) times were recorded.

Results: Paramedics transported 2,712 patients with a PH-ECG diagnosis of STEMI directly to the nearest SRC. A PPCI was performed in 2,053 patients (76%) with an 86% rate of D2B 90 min (95% confidence interval: 84.4% to 87.4%). Secondary analyses of this cohort demonstrated a 50% rate of D2B 60 min (n = 1,031), 25% rate of D2B 45 min (n = 517), and an 8% rate of D2B 30 min (n = 155). A tertiary analysis restricted to 762 of 2,053 (37%) cases demonstrated a 68% rate of E2B 90 min.

Conclusions: Ten independent regional SRC networks demonstrated a combined 86% rate of D2B 90 min, and each region individually surpassed the American College of Cardiology D2B Alliance benchmark. In areas with regional SRC networks, 9-1-1 provides entire communities with timely access to quality STEMI care.

Key Words: D2B Alliance • door-to-balloon time • Mission: Lifeline • pre-hospital electrocardiogram • primary percutaneous coronary intervention • STEMI receiving center networks • ST-elevation myocardial infarction

Abbreviations and Acronyms   AHA-ML = American Heart Association Mission: Lifeline   CCL = cardiac catheterization laboratory   D2B = door-to-balloon time   D2B Alliance = American College of Cardiology D2B: An Alliance in Quality   E2B = emergency medical services-to-balloon time   ED = emergency department   EMS = emergency medical services   PH-ECG = pre-hospital electrocardiogram (12-lead)   PPCI = primary percutaneous coronary intervention   QI = quality improvement   SRC = ST-elevation myocardial infarction receiving center   STEMI = ST-elevation myocardial infarction

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