This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rokos, I. C. Articles by King, S. B. Search for Related Content PubMed Articles by Rokos, I. C. Articles by King, S. B., III Related Collections Related Article

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

	Abstract

Top Abstract Methods Results Discussion Conclusions REFERENCES

 
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

A D2B time within 90 min represents the current benchmark for quality PPCI as promulgated in the American College of Cardiology/American Heart Association STEMI guidelines (1,2) and the Joint Commission Core Measures (3). Each 15-min incremental delay beyond a 90-min D2B time is associated with an increased risk of in-hospital death (4,5). However, nationally <50% of patients are treated within 90 min (6,7), underscoring the challenge in achieving this goal.

In 2006, the American College of Cardiology launched D2B: An Alliance in Quality (D2B Alliance) (8), a large-scale QI-initiative that engaged over 1,000 PPCI-capable hospitals across the nation to target a >75% rate of D2B 90 min. The D2B Alliance emphasized 6 evidence-based in-hospital strategies to improve the rate of timely reperfusion (9). A seventh evidence-based strategy involved the use of a 12-lead pre-hospital electrocardiogram (PH-ECG) to activate the cardiac catheterization laboratory (CCL), but implementation was considered optional because of low use nationally (9).

In the same year, a multidisciplinary group proposed the rationale for establishing STEMI Receiving Center (SRC) Networks, a concept that started on a "grassroots" level in response to the convergence of various external forces (10). Two types of regional STEMI networks were described: inter-hospital transfer and pre-hospital cardiac triage.

Pre-hospital cardiac triage (10) involves universal access via 9-1-1, the identification of STEMI patients by emergency medical services (EMS) personnel with PH-ECGs, and direct transport to the nearest SRC (designated PPCI-capable hospital). Ideally, EMS stabilization and transport of patients with a PH-ECG diagnosis of STEMI should occur almost simultaneously with CCL activation at the receiving hospital. Furthermore, EMS is allowed to bypass non-PPCI-capable hospitals when enroute to the designated PPCI-capable hospital (i.e., the SRC) within an organized regional network.

No comprehensive database evaluating pre-hospital cardiac triage within SRC networks exists in the U.S. However, because D2B time measurement is considered a reliable and nationally standardized performance measure for PPCI quality (11), this study analyzed registry data from 10 independently organized regions with the hypothesis that SRC networks focused upon pre-hospital cardiac triage could provide high rates of timely reperfusion.

	Methods

Top Abstract Methods Results Discussion Conclusions REFERENCES

 
Study design.   Collaboration among 10 independently organized regional SRC networks meeting previously described criteria (10) (Table 1) led to this pooled analysis. Upon initiation of each regional network, a responsible agency was designated to collect and maintain a prospective observational registry focused on continuous QI for D2B times. A locally managed central database was not available for 2 SRC networks (Minneapolis/St. Paul and Royal Oak), but D2B datasets consistent with study criteria were obtained from each participating SRC in the region and aggregated.

View larger version (48K): [in this window] [in a new window] [Download PPT slide]   Figure 1 Location of 10 Independent Regional ST-Elevation Myocardial Infarction Receiving Center Networks

SRC network performance measures.   The primary end point of this analysis was the rate of D2B 90 min in patients with STEMI. Secondary analyses included the rate of D2B 60 min, 45 min, and 30 min. The rate of EMS-to-balloon (E2B) time 90 min was considered a tertiary end point, because only 5 of 10 regions tracked this parameter. "Time Zero" for E2B was previously defined as the date and time auto-stamped on the first PH-ECG that was consistent with an acute STEMI (10,13). Clinical outcomes data were not available.

Statistical methods.   Descriptive analyses (Microsoft Excel, Redmond, Washington) were performed to calculate all end points. The proportion of D2B 90 min versus >90 min was reported both in aggregate and individually for each of the 10 regions. Other end points were reported only in aggregate.

	Results

Top Abstract Methods Results Discussion Conclusions REFERENCES

 
D2B times 90 min.   There were 2,712 patients diagnosed with STEMI by PH-ECG. In the 2,053 (76%) who underwent PPCI, pooled data from all 10 independently managed regions demonstrated an 86% rate (95% confidence interval: 84.4% to 87.4%) of D2B 90 min. When assessed by individual region, the rate of D2B 90 min ranged from 77% to 97% (Table 2, Fig. 2).

View larger version (22K): [in this window] [in a new window] [Download PPT slide]   Figure 2 D2B 90 Min by Region The rate of door-to-balloon (D2B) 90 min for 10 independent regional ST-elevation myocardial infarction (STEMI) receiving center (SRC) networks organized in descending order, on the basis of total number of patients (N) in each region that were pre-hospital electrocardiogram(+) for STEMI and underwent primary percutaneous coronary intervention through August 31, 2007. Regional databases with >400, 400 to 100, and <100 primary percutaneous coronary intervention patients are denoted in dark blue, blue, and light blue, respectively. Dashed red line represents D2B Alliance benchmark rate of 75%. Solid red line denotes 86% rate of D2B 90 min for all 10 regions combined (n = 2,053). Atl = Atlanta, Georgia; Cha = Charlotte, North Carolina; LAC = Los Angeles County, California; Mar = Marin County, California; Med = Medford, Oregon; MSP = Minneapolis/St. Paul, Minnesota; OC = Orange County, California; Roy = Royal Oak, Michigan; SDC = San Diego County, California; Ven = Ventura County, California.

D2B times 60, 45, and 30 min.

E2B times 90 min.   There was a 68% rate of E2B 90 min in this study. The E2B times could be determined in 762 of 2,053 (37%) patients, because only 5 of 10 regions had records that included the time of the first PH-ECG consistent with STEMI: Los Angeles County (442 patients), Minneapolis/St. Paul (100), Medford (85), Charlotte (71), and Ventura County (64).

	Discussion

Top Abstract Methods Results Discussion Conclusions REFERENCES

 
Acquisition of a PH-ECG represents an evidence-based yet underused strategy to reduce D2B times (1,9). Furthermore, a recent American Heart Association (AHA) scientific statement (14) concluded "the central challenge for healthcare providers is not to simply perform a PH-ECG, but to use and integrate the diagnostic information from a PH-ECG with systems of care."

This 10-region QI analysis showed that successful use and broad translation of PH-ECGs could be achieved with the creation of regional SRC networks focused on pre-hospital cardiac triage. Analysis of 2,053 consecutive STEMI patients treated with PPCI demonstrated an 86% rate of D2B 90 min (Table 3), thus providing proof-of-concept for the conclusions in the AHA statement (14). Importantly, these individual regions included from 1 to 30 SRCs, and each independently exceeded the D2B Alliance benchmark rate of 75% (8).

Another unique finding of the current analysis was demonstrated by the 68% rate of E2B 90 min for patients treated in the 5 regions that prospectively tracked this variable (Table 3). Following initial proposals (10,13), our data provides the first evidence that the rate of E2B 90 min may represent an appropriate metric for assessing the performance of coordinated regional STEMI care systems. A theoretical construct for achieving an E2B 90 min in urban/suburban settings is the 30-30-30 goal, wherein the 3 provider units (EMS, ED, CCL) work in rapid succession and each complete their unique duties within 30 min (13).

Of patients identified by PH-ECG with presumed STEMI, 24% percent were not treated with PPCI, as compared with a 14% rate reported by a large inter-hospital transfer network (17). However, the exact rate of false-positive CCL activations could not be determined in our 10-region analysis. The relative frequency in which the CCL team was never activated by the on-duty ED physician (despite a PH-ECG with presumed STEMI) or clinical scenarios of angiography without PPCI was not tracked. Also, uncertainty about the best definition of false-positive CCL activations continues to exist (17).

Baseline rates of D2B 90 min for each region before SRC network implementation were unavailable, except for Los Angeles County. Analysis of D2B times during 2005 at 4 major Los Angeles County hospitals showed a <50% rate of D2B 90 min for EMS-transported STEMI patients, even though PH-ECG use by EMS providers was routine (18). However, after the formal implementation of a regionalized SRC network protocol in Los Angeles County on December 1, 2006, there was an immediate, substantial, and sustained improvement in reperfusion times for EMS-transported STEMI patients demonstrated by a 90% aggregate rate of D2B 90 min for 30 hospitals newly designated as SRCs (Fig. 3). The strong association between high rates of D2B 90 min and SRC network implementation is clinically significant, and it is unlikely to have been caused by unmeasured confounders across 30 different hospitals in Los Angeles County.

View larger version (18K): [in this window] [in a new window] [Download PPT slide]   Figure 3 Los Angeles County SRC Network Rate of D2B 90 min Temporal trends displayed by month (blue) for the rate of door-to-balloon (D2B) 90 min in Los Angeles County (California) December 1, 2006 through August 31, 2007. The network started with 3 hospitals and grew rapidly to 30 designated ST-elevation myocardial infarction (STEMI) receiving centers (SRCs) within this time period. (N) denotes number of patients with D2B data for each given month. Red line denotes overall 90% rate of D2B 90 min (n = 476). An approximate baseline from a 2005 survey (17) of pre-hospital electrocardiogram-identified STEMI patients is depicted as "Pre-SRC" (green).

Two recent studies further bolster our findings. First, a regionalized STEMI system from Ottawa (Ontario, Canada) demonstrated a 79.7% rate of D2B 90 min in 135 patients identified by EMS and transported directly to the city's 1 designated SRC (24). Furthermore, the Ottawa program provided additional evidence that pre-hospital cardiac triage is preferred over a strategy of inter-hospital transfer, because only 11.9% of patients transferred between hospitals achieved a first-door-to-balloon 90 min. Four other comprehensive inter-hospital transfer networks have also not been able to exceed a 50% rate of first door-to-balloon 90 min (25–28).

Second, data from the 2007 ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry demonstrated only a 17.6% use rate of the PH-ECG in patients with STEMI. Importantly, patients with a PH-ECG had a significantly shorter median D2B time compared with those without (63 min vs. 81 min, p < 0.0001) (29). The quartile of patients with the fastest reperfusion in this cohort had D2B times of 49 min or less, a finding that was consistent with our 10-region experience.

Across the nation, efforts to create regional STEMI networks continue to accelerate through the convergence of many independent initiatives beyond the D2B Alliance. For example, a 2006 Institute of Medicine report recommended "the emergency care system of the future should be highly regionalized, coordinated, and accountable" (23). In 2007, the AHA Mission: Lifeline (AHA-ML) initiative (30) began to translate the current "grassroots" initiative of regionalized STEMI care into an organized national effort.

The EMS-organized pre-hospital cardiac triage networks have enabled paramedics to diagnose STEMI and thus identify patients that should enter a priority track to the closest available PPCI team, a key systems feature needed in the current era of ED overcrowding and ambulance diversions (23). In contrast, current barriers to timely identification of cardiac ischemia by ED triage staff are significant, with a recent registry analysis of non-STEMI patients demonstrating that only 34% receive an ECG within 10 min of arrival (31).

Finally, PPCI-capable hospitals must recognize that EMS is responsible for the delivery of approximately one-half of all STEMI patients (32), and thus EMS is in a unique and powerful position to foster collaboration among competing hospitals and drive QI in a region. An EMS agency can ensure consistently fast reperfusion for patients who call 9-1-1 by creating protocols in which STEMI patients are transported only to designated SRCs that have agreed to submit D2B and E2B data (and other appropriate parameters) back to the organization responsible for regional quality oversight.

Study limitations.   Although we were unable to report on clinical outcomes, the study primary end point (D2B 90 min) is strongly associated with low in-hospital mortality (4,5). Thus on the basis of the classic Donabedian model (33) of quality, it is reasonable to expect better patient outcomes when regional STEMI networks provide improvements in both structure and process-of-care.

This 10-region SRC network data focused on achieving high rates of D2B 90 min represented an early experience that is consistent with accepted standards of QI methodology (34,35). Although conventional experimental study information (i.e., patient characteristics and comorbidities, comprehensive pre-network D2B rates, E2B rates for all 10 regions, a standardized approach to tracking false-positive CCL-activations, variable resources for source data audits, or incomplete regionalization in certain areas) was not available, this deficiency should not detract from the finding that high rates of D2B 90 min are consistently achievable in "real world" SRC networks.

Similarly, the inclusion of only "successful" SRC networks in this analysis is also appropriate, because the initial uptake of QI initiatives is often patchy and limited to "innovators and early adopters"(36). Furthermore, although not all existing SRC networks in the U.S. agreed to participate in our pooled analysis, we are not aware of any pre-hospital cardiac triage systems in the U.S. with low rates of D2B 90 min. Finally, concerns about selection bias on the patient level are mitigated by the inclusion within each SRC network database of all consecutive patients diagnosed with presumed STEMI by paramedics.

Future directions.   Based upon this successful SRC network experience across 10 independent regions, we propose 3 areas of focus as STEMI regionalization expands across the nation. In reporting time-zero for E2B, our analysis used the PH-ECG time as previously defined (10,13), whereas the most recent STEMI guidelines use time of EMS arrival on scene (1). In reality, the true patient-centered time-zero for STEMI systems is time of 9-1-1 call, and hence this time-point represents the ideal starting point of E2B that should be tracked in future analyses. Time of EMS alarm/dispatch (usually occurring within a few minutes of 9-1-1 call initiation) is generally documented by paramedics and represents a reasonable surrogate for this ideal time-zero.

Second, any STEMI registry supporting the AHA-ML initiative and tracking overall resource use needs to broaden its entry criteria as previously proposed (37). Subsequent events for all patients with a PH-ECG interpreted as presumed STEMI need to be prospectively tracked. This approach, as performed in our 10-region study, provides the true denominator of STEMI system activations.

Third, minimizing false-positive CCL activations is of potential interest for both interventional cardiologists and hospital administrators. The automated computer algorithm (Table 2) was the most frequently used in this study of the 3 existing PH-ECG interpretation strategies (14), because it could be rapidly implemented across large EMS systems and was considered reasonably accurate (10). However, given the real-world occurrence of incorrect computer algorithm analyses for various technical reasons, some regions have taken a Bayesian approach (38) and set strict criteria for paramedic diagnosis of STEMI and CCL activation. For other regions, PH-ECG activation of the CCL has evolved into a 2-step process in which the on-duty ED physician served as the filter after radio communication with EMS. The ED physician then decided in real-time (24/7) which pre-hospital "STEMI Alert" merits conversion to an in-hospital "Code STEMI" involving CCL activation before patient arrival and which patients need further assessment in the ED to determine whether CCL activation is warranted (39). Simultaneous use of all 3 PH-ECG interpretation strategies might be the best approach in the future, because evidence suggests that the accuracy of in-hospital Code STEMI activation can be further optimized by PH-ECG wireless transmission and physician interpretation (Wi-PI) (14,39). Further study is warranted.

	Conclusions

Top Abstract Methods Results Discussion Conclusions REFERENCES

 
Our 10-region "grassroots" D2B and E2B dataset involving 72 hospitals, despite inherent limitations, provided credible evidence supporting the AHA-ML vision of a national network of coordinated and efficient STEMI systems that are supported by a comprehensive national registry (30,37). The key systems achievement of SRC networks is the successful integration of PH-ECG identification of STEMI patients with immediate transport and early activation of the CCL team. In areas with regional SRC networks, 9-1-1 provides entire communities with timely access to quality STEMI care.

	Acknowledgments

 
The authors would like to formally thank a very large, enthusiastic, and multidisciplinary group of individuals from each of the 10 independent SRC networks whose efforts were critically important during the many phases of each local "grassroots" initiative: consensus building, systems planning, network launch, long-term implementation, and/or quality surveillance. Also, in remembrance, the authors would like to honor Bill Jermyn, MD (STEMI activist, Missouri) and Beverly Nighswonger, RN (co-author, California).

^_* 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).

Manuscript received September 23, 2008; revised manuscript received November 18, 2008, accepted November 19, 2008.

	REFERENCES

Top Abstract Methods Results Discussion Conclusions REFERENCES

 

1. Antman EM, Hand M, Armstrong PW, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction J Am Coll Cardiol 2008;51:210-247.[Free Full Text]
2. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (Committee to Revise the 1999 Guidelines) J Am Coll Cardiol 2004;44:671-719.[Free Full Text]
3. Joint Commission Core Measures http://www.coreoptions.com/new_site/jcahocore.html 2004Accessed January 4, 2008.
4. McNamara RL, Wang Y, Herrin J, et al. Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction J Am Coll Cardiol 2006;47:2180-2186.[Abstract/Free Full Text]
5. Nallamothu BK, Bradley EH, Krumholz HM. Time to treatment in primary percutaneous coronary intervention N Engl J Med 2007;357:1631-1638.[CrossRef][Web of Science][Medline]
6. McNamara RL, Herrin J, Bradley EH, et al. Hospital improvement in time to reperfusion in patients with acute myocardial infarction, 1999 to 2002 J Am Coll Cardiol 2006;47:45-51.[Abstract/Free Full Text]
7. Magid DJ, Wang Y, Herrin J, et al. Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction JAMA 2005;294:803-812.[Abstract/Free Full Text]
8. Nissen SE, Brush Jr. JE, Krumholz HM. President's page: GAP-D2B: an alliance for quality J Am Coll Cardiol 2006;48:1911-1912.[Free Full Text]
9. Bradley EH, Herrin J, Wang Y, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction N Engl J Med 2006;355:2308-2320.[CrossRef][Medline]
10. Rokos IC, Larson DM, Henry TD, et al. Rationale for establishing regional ST-elevation myocardial infarction receiving center (SRC) networks Am Heart J 2006;152:661-667.[CrossRef][Web of Science][Medline]
11. Krumholz HM, Anderson JL, Brooks NH, et al. ACC/AHA clinical performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction J Am Coll Cardiol 2006;47:236-265.[Free Full Text]
12. US Department of Health and Human Services, HIPAA Privacy Rule, version January 2004 http://privacyruleandresearch.nih.gov/research_repositories.asp 2006Accessed January 4, 2008.
13. Rokos IC, Bouthillet T. The emergency medical services-to-balloon (E2B) challenge: building on the foundations of the D2B Alliance http://stemisystems.org/ 2006Accessed January 9, 2008.
14. Ting HH, Krumholz HM, Bradley EH, et al. Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome: a scientific statement from the American Heart Association Circulation 2008;118:1066-1079.[Free Full Text]
15. Antman EM. Time is muscle: translation into practice J Am Coll Cardiol 2008;52:1216-1221.[Abstract/Free Full Text]
16. Rathore SS, Curtis JP, Chen J, et al. Issues in STEMI care: DTB times, transfers and the ECG. Primary percutaneous coronary intervention door-to-balloon time and mortality in patients hospitalized with ST-elevation myocardial infarction: is 90 minutes fast enough (abstr) Circulation 2008;18(Suppl):1074.
17. Larson DM, Menssen KM, Sharkey SW, et al. "False-positive" cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction JAMA 2007;298:2754-2760.[Abstract/Free Full Text]
18. Eckstein M, Pratt FD, Cooper EM, Nguyen T. Impact of paramedic transport with out-of-hospital 12-lead ECG on door-to-balloon times for STEMI patients (abstr) Ann Emerg Med 2007;50:S56.
19. US Department of Health and Human Services Hospital Compare results provided July 2006 through December 2006 for "Percent of US Heart Attack Patients Given PCI within 90 Minutes of Arrival." http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp 2007Accessed November 27, 2007.
20. Mehta RH, Bufalino VJ, Pan W, et al. Achieving rapid reperfusion with primary percutaneous coronary intervention remains a challenge: insights from American Heart Association's Get With the Guidelines program Am Heart J 2008;155:1059-1067.[CrossRef][Web of Science][Medline]
21. National Cardiovascular Data Registry, ACTION 2nd Quarter 2007 rate of D2B 90 minutes http://cs.acc.org/guidelinefocus/gfc_stemi.asp 2008Accessed January 2, 2008.
22. National Cardiovascular Data Registry, Cath-PCI 2nd Quarter 2007 rate of D2B 90 minutes www.ncdr.com/webncdr/DefaultCathPCI.aspx 2008Accessed January 9, 2008.
23. IOM Institute of Medicine Report: The Future of Emergency Care in the United States Health System (Report Brief). National Academies Press www.iom.edu 2008Accessed June 14, 2006.
24. Le May MR, So DY, Dionne R, et al. A citywide protocol for primary PCI in ST-segment elevation myocardial infarction N Engl J Med 2008;358:231-240.[CrossRef][Web of Science][Medline]
25. Henry TD, Sharkey SW, Burke Minnesota, et al. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction Circulation 2007;116:721-728.[Abstract/Free Full Text]
26. Ting HH, Rihal CS, Gersh BJ, et al. Regional systems of care to optimize timeliness of reperfusion therapy for ST-elevation myocardial infarction: the Mayo Clinic STEMI Protocol Circulation 2007;116:729-736.[Abstract/Free Full Text]
27. Jollis JG, Roettig ML, Aluko AO, et al. Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction JAMA 2007;298:2371-2380.[Abstract/Free Full Text]
28. Aguirre FV, Varghese JJ, Kelley MP, et al. Rural interhospital transfer of ST-elevation myocardial infarction patients for percutaneous coronary revascularization: the Stat Heart Program Circulation 2008;117:1145-1152.[Abstract/Free Full Text]
29. Diercks DB, Lynch J, Kontos MC, et al. Pre-hospital electrocardiograms: potential answer to the time to reperfusion challenge (abstr) J Am Coll Cardiol 2008;51:A209.
30. Jacobs AK, Antman EM, Faxon DP, Gregory T, Solis P. Development of systems of care for ST-elevation myocardial infarction patients: executive summary Circulation 2007;116:217-230.[Free Full Text]
31. Diercks DB, Roe MT, Chen AY, et al. Prolonged emergency department stays of non-ST-segment-elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/American Heart Association guidelines for management and increased adverse events Ann Emerg Med 2007;50:489-496.[CrossRef][Web of Science][Medline]
32. Canto JG, Zalenski RJ, Ornato JP, et al. Use of emergency medical services in acute myocardial infarction and subsequent quality of care: observations from the National Registry of Myocardial Infarction 2 Circulation 2002;106:3018-3023.[Abstract/Free Full Text]
33. Donabedian A. Evaluating the quality of medical care Milbank Mem Fund Q 1966;44:166-206.[CrossRef][Web of Science][Medline]
34. Krumholz HM. Outcomes research: generating evidence for best practice and policies Circulation 2008;118:309-318.[Free Full Text]
35. Berwick DM. The science of improvement JAMA 2008;299:1182-1184.[Free Full Text]
36. Berwick DM. Disseminating innovations in health care JAMA 2003;289:1969-1975.[Abstract/Free Full Text]
37. Peterson ED, Ohman EM, Brindis RG, Cohen DJ, Magid DJ. Development of systems of care for ST-elevation myocardial infarction patients: evaluation and outcomes Circulation 2007;116:e64-e67.[Free Full Text]
38. Youngquist ST, Kaji AH, Lipsky AM, Koenig WJ, Niemann JT. A Bayesian sensitivity analysis of out-of-hospital 12-lead electrocardiograms: implications for regionalization of cardiac care Acad Emerg Med 2007;14:1165-1171.[CrossRef][Web of Science][Medline]
39. Landman A, Rokos IC, French WJ, Gross B. Optimizing prehospital wireless ECG transmission: new data, new ideas http://stemisystems.org/ 2007Accessed January 9, 2008.

This article has been cited by other articles:

				J. L. Garvey, L. Monk, C. B. Granger, J. R. Studnek, M. L. Roettig, C. C. Corbett, and J. G. Jollis Rates of Cardiac Catheterization Cancelation for ST-Segment Elevation Myocardial Infarction After Activation by Emergency Medical Services or Emergency Physicians: Results From the North Carolina Catheterization Laboratory Activation Registry Circulation, January 17, 2012; 125(2): 308 - 313. [Abstract] [Full Text] [PDF]

				J. G. Jollis Moving Care Forward: Prehospital Emergency Cardiac Systems Circulation, October 12, 2010; 122(15): 1443 - 1445. [Full Text] [PDF]

				H.-J. Dieker, S. S. B. Liem, H. El Aidi, P. van Grunsven, W. R. M. Aengevaeren, M. A. Brouwer, and F. W. A. Verheugt Pre-Hospital Triage for Primary Angioplasty: Direct Referral to the Intervention Center Versus Interhospital Transport J. Am. Coll. Cardiol. Intv., July 1, 2010; 3(7): 705 - 711. [Abstract] [Full Text] [PDF]

				A. K. Jacobs and C. P. Hochberg Changing Direction in ST-Segment Elevation Myocardial Infarction Care: Where Do We Go From Here? J. Am. Coll. Cardiol. Intv., July 1, 2010; 3(7): 712 - 714. [Full Text] [PDF]

				S. R. Pitta, L. A. Myers, C. M. Bjerke, R. D. White, and H. H. Ting Using Prehospital Electrocardiograms to Improve Door-to-Balloon Time for Transferred Patients With ST-Elevation Myocardial Infarction: A Case of Extreme Performance Circ Cardiovasc Qual Outcomes, January 1, 2010; 3(1): 93 - 97. [Full Text] [PDF]

				A. W. Hutchison, Y. Malaiapan, I. Jarvie, B. Barger, E. Watkins, G. Braitberg, T. Kambourakis, J. D. Cameron, and I. T. Meredith Prehospital 12-Lead ECG to Triage ST-Elevation Myocardial Infarction and Emergency Department Activation of the Infarct Team Significantly Improves Door-to-Balloon Times: Ambulance Victoria and MonashHEART Acute Myocardial Infarction (MonAMI) 12-Lead ECG Project Circ Cardiovasc Interv, December 1, 2009; 2(6): 528 - 534. [Abstract] [Full Text] [PDF]

				N. Danchin Systems of Care for ST-Segment Elevation Myocardial Infarction: Impact of Different Models on Clinical Outcomes J. Am. Coll. Cardiol. Intv., October 1, 2009; 2(10): 901 - 908. [Abstract] [Full Text] [PDF]

				A. M. Ross, K. Huber, U. Zeymer, P. W. Armstrong, C. B. Granger, P. Goldstein, K. Bogaerts, and F. Van de Werf The Impact of Place of Enrollment and Delay to Reperfusion on 90-Day Post-Infarction Mortality in the ASSENT-4 PCI Trial: Assessment of the Safety and Efficacy of a New Treatment Strategy With Percutaneous Coronary Intervention J. Am. Coll. Cardiol. Intv., October 1, 2009; 2(10): 925 - 930. [Abstract] [Full Text] [PDF]

				S. B. King III "If You Have a Heart Attack, Just Cough" J. Am. Coll. Cardiol. Intv., October 1, 2009; 2(10): 1032 - 1033. [Full Text] [PDF]

				C. B. Granger Accelerating ST-Segment Elevation Myocardial Infarction Care: Emergency Medical Services Take Center Stage J. Am. Coll. Cardiol. Intv., April 1, 2009; 2(4): 347 - 349. [Full Text] [PDF]

This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rokos, I. C. Articles by King, S. B. Search for Related Content PubMed Articles by Rokos, I. C. Articles by King, S. B., III Related Collections Related Article