title: Cardiac Outcomes Through Digital Evaluation (CODE) STEMI project: prehospital digitally-assisted reperfusion strategies.
abstract: BACKGROUND
  Guidelines for reperfusion in ST-elevation myocardial infarction (STEMI) were recently adopted by the Canadian Cardiovascular Society. We have developed a blended model of prehospital thrombolytic (PHL) therapy or primary percutaneous coronary intervention (PPCI) activation, in order to achieve guideline times.
  
  
  METHODS
  In our urban centre of 658,700 people, emergency medical services (EMS) were trained to perform and screen electrocardiograms (ECGs) for suspected STEMI. Suspected ECGs were transmitted to a physician's hand-held device. If the physician confirmed the diagnosis they coordinated initiation of either PHL or PPCI. In cases where physicians found the prehospital ECG negative for STEMI (PHENST), patients were transported to the closest emergency room.
  
  
  RESULTS
  From July 21, 2008 to July 21, 2010, the Cardiac Outcomes Through Digital Evaluation (CODE) STEMI project received 380 transmitted calls. There were 226 confirmed STEMI by the on-call physician, 158 (70%) received PPCI, 48 (21%) received PHL, and 20 (9%) had angiography but no revascularization. The PPCI, median time from first medical contact to reperfusion was 76 minutes (interquartile range [IQR], 64-93). For PHL, median time from first medical contact to needle was 32 minutes (IQR, 29-39). The overall mortality rate for the STEMI patients was 8% (PHL = 4 [8.3%], PPCI = 8 [5%], medical therapy = 7 [35%]). There were 154 PHENST patients, 44% later diagnosed with acute coronary syndrome. The mortality rate for PHENST was 14%.
  
  
  CONCLUSIONS
  Through a model of EMS prehospital ECG interpretation, digital transmission, direct communication with a physician, and rapid coordinated service, we demonstrate that benchmark reperfusion times in STEMI can be achieved.
authors.affiliation: University of Manitoba, Winnipeg, Manitoba, Canada. umducasr@cc.umanitoba.ca
authors.forename: Robin A
authors.initials: RA
authors.lastname: Ducas
authors.forename: Roger K
authors.initials: RK
authors.lastname: Philipp
authors.forename: Davinder S
authors.initials: DS
authors.lastname: Jassal
authors.forename: Anthony W
authors.initials: AW
authors.lastname: Wassef
authors.forename: Erin
authors.initials: E
authors.lastname: Weldon
authors.forename: Farrukh
authors.initials: F
authors.lastname: Hussain
authors.forename: Christian
authors.initials: C
authors.lastname: Schmidt
authors.forename: Aliasghar
authors.initials: A
authors.lastname: Khadem
authors.forename: John
authors.initials: J
authors.lastname: Ducas
authors.forename: Rob
authors.initials: R
authors.lastname: Grierson
authors.forename: James W
authors.initials: JW
authors.lastname: Tam
mesh_terms: D000046:Academic Medical Centers; D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000628:therapy; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000193:education / Q000379:methods*; D002637:Chest Pain / Q000209:etiology*; D034201:Computers, Handheld; D017023:Coronary Angiography; D001026:Coronary Artery Bypass; D004562:Electrocardiography; D004632:Emergency Medical Services / Q000379:methods*; D004634:Emergency Medical Technicians / Q000193:education*; D005260:Female; D019983:Guideline Adherence / Q000592:standards*; D006786:Hospitals, Urban; D006801:Humans; D007318:Inservice Training; D008297:Male; D008350:Manitoba; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D012815:Signal Processing, Computer-Assisted; D015996:Survival Rate; D017216:Telemedicine; D015912:Thrombolytic Therapy / Q000379:methods*; D013996:Time and Motion Studies