title: Impact of a Rural Regional Myocardial Infarction System of Care in Wyoming.
abstract: Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for patients presenting with ST-segment elevation myocardial infarction; however, to be effective, PCI must be performed in a timely manner. Rural regions are at a severe disadvantage, given the relatively sparse number of PCI hospitals and long transport times.
  
  
  
  We developed a standardized treatment and transfer protocol for ST-segment elevation myocardial infarction in the rural state of Wyoming. The study design compared the time-to-treatment outcomes during the pre- and postintervention periods. Details of the program, changes in reperfusion strategies over time, and outcome improvements in treatment times were reported. From January 1, 2013, to December 31, 2014, 889 patients were treated in 11 PCI-capable hospitals (4 in Wyoming, 7 in adjoining states). Given the large geographic distance in the state (median of 47 miles between patient and PCI center), 52% of all patients were transfers, and 36% were administered fibrinolysis at the referral facility. Following the intervention, there was a significant shift toward greater use of primary PCI as the dominant reperfusion strategy (from 47% to 60%, P=0.002), and the median total ischemic time from symptom onset to arterial reperfusion was decreased by 92 minutes (P<0.001). There was a similar significant reduction in median time from receiving center door to balloon of 11 minutes less than the baseline time (P<0.01).
  
  
  
  Rural systems of care for ST-segment elevation myocardial infarction require increased levels of cooperation between emergency medical services agencies and hospitals. This study confirms that total ischemic times can be reduced through a coordinated rural statewide initiative.
authors.affiliation: University of Texas Health Science Center, Houston, TX james.r.langabeer@uth.tmc.edu.
authors.forename: James R
authors.initials: JR
authors.lastname: Langabeer
authors.affiliation: University of Wyoming, Laramie, WY.
authors.forename: Derek T
authors.initials: DT
authors.lastname: Smith
authors.affiliation: University of Texas Health Science Center, Houston, TX.
authors.forename: Marylou
authors.initials: M
authors.lastname: Cardenas-Turanzas
authors.affiliation: American Heart Association, Denver, CO.
authors.forename: Benjamin L
authors.initials: BL
authors.lastname: Leonard
authors.affiliation: American Heart Association, Denver, CO.
authors.forename: Wendy
authors.initials: W
authors.lastname: Segrest
authors.affiliation: South Lincoln Medical Center, Kemmerer, WY.
authors.forename: Chris
authors.initials: C
authors.lastname: Krell
authors.affiliation: University of Utah, Salt Lake City, UT.
authors.forename: Theophilus
authors.initials: T
authors.lastname: Owan
authors.affiliation: Private Practice, Casper, WY.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Eisenhauer
authors.affiliation: Campbell County Memorial Hospital, Gillette, WY.
authors.forename: Daniela
authors.initials: D
authors.lastname: Gerard
mesh_terms: D000368:Aged; D003695:Delivery of Health Care / Q000458:organization & administration*; D004632:Emergency Medical Services; D005260:Female; D006761:Hospitals; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000601:surgery; D010360:Patient Transfer; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D011787:Quality of Health Care; D012040:Regional Health Planning; D012424:Rural Population; D000072657:ST Elevation Myocardial Infarction / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D061665:Time-to-Treatment; D014959:Wyoming
keywords: ST‐segment elevation myocardial infarction; outcomes research; primary percutaneous coronary intervention; quality of care; systems of care