title: Bypassing the emergency department and time to reperfusion in patients with prehospital ST-segment-elevation: findings from the reperfusion in acute myocardial infarction in Carolina Emergency Departments project.
abstract: BACKGROUND
  Among patients identified prehospital with ST-segment-elevation myocardial infarction, emergency medical service transport from the field directly to the catheterization laboratory, thereby bypassing the emergency department (ED), may shorten time to reperfusion.
  
  
  RESULTS
  We studied 1687 patients identified prehospital with ST-segment-elevation myocardial infarction from the Reperfusion in Acute Myocardial Infarction in Carolina Emergency Departments (RACE) project, transported via emergency medical service directly to 21 North Carolina hospitals for primary percutaneous coronary intervention between July 2008 and December 2009. Treatment time intervals were compared between patients evaluated in the ED (ED evaluation) and those transported directly to the catheterization laboratory (ED bypass). Emergency medical service transported 1401 (83.0%) patients to the ED, whereas the ED was bypassed for 286 (17.0%) patients. Overall, first medical contact to device activation within 90 minutes was achieved in 913 (54.1%) patients. Among patients evaluated in the ED, median time (25th-75th percentiles) from ED arrival to catheterization laboratory arrival was 30 (20-41) minutes. First medical contact to device activation occurred faster (75 [59-93] versus 90 [76-109] minutes; P<0.001) and was more frequently achieved within 90 minutes (74.1% versus 50.1%; P<0.001) among ED bypass patients.
  
  
  CONCLUSIONS
  Among patients identified prehospital with ST-segment-elevation myocardial infarction and transported directly to a percutaneous coronary intervention hospital, only 1 in 2 achieve device activation within 90 minutes. A median of 30 minutes is spent in the ED, contributing significantly to the failure to achieve timely reperfusion. The strategy to bypass the ED is used infrequently and represents a potential opportunity to improve reperfusion times.
authors.affiliation: Department of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC 27705, USA. akshay.bagai@duke.edu
authors.forename: Akshay
authors.initials: A
authors.lastname: Bagai
authors.forename: Hussein R
authors.initials: HR
authors.lastname: Al-Khalidi
authors.forename: Daniel
authors.initials: D
authors.lastname: Muñoz
authors.forename: Lisa
authors.initials: L
authors.lastname: Monk
authors.forename: Mayme L
authors.initials: ML
authors.lastname: Roettig
authors.forename: Claire C
authors.initials: CC
authors.lastname: Corbett
authors.forename: J Lee
authors.initials: JL
authors.lastname: Garvey
authors.forename: B Hadley
authors.initials: BH
authors.lastname: Wilson
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Granger
authors.forename: James G
authors.initials: JG
authors.lastname: Jollis
mesh_terms: D000368:Aged; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000628:therapy*; D015425:Myocardial Reperfusion; D062645:Percutaneous Coronary Intervention; D013997:Time Factors
keywords: health care systems; myocardial infarction; percutaneous coronary intervention