title: Symptom-to-needle times in ST-segment elevation myocardial infarction: shortest route to a primary coronary intervention facility.
abstract: BACKGROUND
  Primary percutaneous coronary intervention (PCI) is the preferred management for patients with acute ST-segment elevation myocardial infarction (STEMI) if performed in a timely manner by experienced providers. Patients can access a PCI facility by three routes: prehospital STEMI diagnosis by emergency medical services (EMS) and direct transport by EMS to a PCI facility (EMS-PCI); visit to a hospital emergency department (ED) followed by referral to an on-site PCI facility (ED-PCI); or transfer from the ED to a PCI facility in another hospital (ED-transfer-PCI).
  
  
  OBJECTIVE
  To assess the implementation rate in France of the guidelines recommending that STEMI patients be transported by EMS to a PCI facility and to compare the times between symptom onset and PCI for these three routes.
  
  
  METHODS
  We used the results of the pilot testing of a national quality indicator programme on STEMI in 64 hospitals, providing data on patient characteristics, referral route and symptom-onset-to-needle time. We compared delays for each route in a Cox proportional-hazard model.
  
  
  RESULTS
  In a population of 1217 patients, median symptom-onset-to-needle time was 186minutes (Q1 133; Q3 292) for the EMS-PCI route, 237minutes (Q1 165; Q3 368) for the ED-PCI route and 305minutes (Q1 230; Q3 570) for the ED-transfer-PCI route. A total of 70.8% of patients were transported by EMS as recommended. After adjustment for age, symptom onset period (weekends/nights) and history of cardiovascular disease, the EMS-PCI route was associated with the shortest symptom-onset-to-needle times. The hazard ratio was 0.71 [0.59-0.86] for the ED-PCI route and 0.67 [0.52-0.86] for the ED-transfer-PCI route.
  
  
  CONCLUSIONS
  STEMI patients receive prompter care after prehospital diagnosis and direct transport to a PCI facility by EMS than by visiting a hospital ED. Use of this referral route should be further encouraged in France as approximately one-third of STEMI patients are still presenting directly to the ED.
authors.affiliation: Projet COMPAQ-HPST, Inserm U988, Institut Gustave-Roussy, 114, rue Édouard-Vaillant, 4(e) étage, 94805 Villejuif cedex, France. Henri.leleu@igr.fr
authors.forename: Henri
authors.initials: H
authors.lastname: Leleu
authors.forename: Frédéric
authors.initials: F
authors.lastname: Capuano
authors.forename: Marie
authors.initials: M
authors.lastname: Ferrua
authors.forename: Gérard
authors.initials: G
authors.lastname: Nitenberg
authors.forename: Etienne
authors.initials: E
authors.lastname: Minvielle
authors.forename: François
authors.initials: F
authors.lastname: Schiele
mesh_terms: D039602:After-Hours Care; D000368:Aged; D000369:Aged, 80 and over; D000552:Ambulances / Q000592:standards; D016009:Chi-Square Distribution; D004632:Emergency Medical Services / Q000592:standards; D004636:Emergency Service, Hospital / Q000592:standards; D005602:France; D019983:Guideline Adherence; D006801:Humans; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000628:therapy*; D010343:Patient Admission; D010360:Patient Transfer / Q000592:standards; D062645:Percutaneous Coronary Intervention / Q000592:standards; D010865:Pilot Projects; D017410:Practice Guidelines as Topic; D016016:Proportional Hazards Models; D019984:Quality Indicators, Health Care; D012017:Referral and Consultation; D013997:Time Factors; D061665:Time-to-Treatment / Q000592:standards; D016896:Treatment Outcome; D014218:Triage