title: A citywide protocol for primary PCI in ST-segment elevation myocardial infarction.
abstract: BACKGROUND
  If primary percutaneous coronary intervention (PCI) is performed promptly, the procedure is superior to fibrinolysis in restoring flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction. The benchmark for a timely PCI intervention has become a door-to-balloon time of less than 90 minutes. Whether regional strategies can be developed to achieve this goal is uncertain.
  
  
  METHODS
  We developed an integrated-metropolitan-area approach in which all patients with ST-segment elevation myocardial infarction were referred to a specialized center for primary PCI. We sought to determine whether there was a difference in door-to-balloon times between patients who were referred directly from the field by paramedics trained in the interpretation of electrocardiograms and patients who were referred by emergency department physicians.
  
  
  RESULTS
  Between May 1, 2005, and April 30, 2006, a total of 344 consecutive patients with ST-segment elevation myocardial infarction were referred for primary PCI: 135 directly from the field and 209 from emergency departments. Primary PCI was performed in 93.6% of patients. The median door-to-balloon time was shorter in patients referred from the field (69 minutes; interquartile range, 43 to 87) than in patients needing interhospital transfer (123 minutes; interquartile range, 101 to 153; P<0.001). Door-to-balloon times of less than 90 minutes were achieved in 79.7% of patients who were transferred from the field and in 11.9% of those transferred from emergency departments (P<0.001).
  
  
  CONCLUSIONS
  Guideline door-to-balloon-times were more often achieved when trained paramedics independently triaged and transported patients directly to a designated primary PCI center than when patients were referred from emergency departments.
authors.affiliation: University of Ottawa Heart Institute, Ottawa, ON, Canada. mlemay@ottawaheart.ca
authors.forename: Michel R
authors.initials: MR
authors.lastname: Le May
authors.forename: Derek Y
authors.initials: DY
authors.lastname: So
authors.forename: Richard
authors.initials: R
authors.lastname: Dionne
authors.forename: Chris A
authors.initials: CA
authors.lastname: Glover
authors.forename: Michael P V
authors.initials: MP
authors.lastname: Froeschl
authors.forename: George A
authors.initials: GA
authors.lastname: Wells
authors.forename: Richard F
authors.initials: RF
authors.lastname: Davies
authors.forename: Heather L
authors.initials: HL
authors.lastname: Sherrard
authors.forename: Justin
authors.initials: J
authors.lastname: Maloney
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Marquis
authors.forename: Edward R
authors.initials: ER
authors.lastname: O'Brien
authors.forename: John
authors.initials: J
authors.lastname: Trickett
authors.forename: Pierre
authors.initials: P
authors.lastname: Poirier
authors.forename: Sheila C
authors.initials: SC
authors.lastname: Ryan
authors.forename: Andrew
authors.initials: A
authors.lastname: Ha
authors.forename: Phil G
authors.initials: PG
authors.lastname: Joseph
authors.forename: Marino
authors.initials: M
authors.lastname: Labinaz
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000592:standards*; D006328:Cardiac Catheterization; D002985:Clinical Protocols / Q000592:standards*; D017023:Coronary Angiography; D004562:Electrocardiography; D004632:Emergency Medical Services / Q000592:standards*; D004634:Emergency Medical Technicians; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000628:therapy*; D010360:Patient Transfer / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic / Q000592:standards; D012017:Referral and Consultation / Q000592:standards; D013997:Time Factors; D016896:Treatment Outcome; D014218:Triage; D019037:Urban Health Services / Q000592:standards