title: Achieving timely percutaneous reperfusion for rural ST-elevation myocardial infarction patients by direct transport to an urban PCI-hospital.
abstract: BACKGROUND
  ST-elevation myocardial infarction (STEMI) guidelines recommend reperfusion by primary percutaneous coronary intervention (PCI) ≤ 90 min from time of first medical contact (FMC). This strategy is challenging in rural areas lacking a nearby PCI-capable hospital. Recommended reperfusion times can be achieved for STEMI patients presenting in rural areas without a nearby PCI-capable hospital by ground transportation to a central PCI-capable hospital by use of protocol-driven emergency medical service (EMS) STEMI field triage protocol.
  
  
  METHODS
  Sixty STEMI patients directly transported by EMS from three rural counties (Nassau, Camden and Charlton Counties) within a 50-mile radius of University of Florida Health-Jacksonville (UFHJ) from 01/01/2009 to 12/31/2013 were identified from its PCI registry. The STEMI field triage protocol incorporated three elements: (1) a cooperative agreement between each of the rural emergency medical service (EMS) agency and UFHJ; (2) performance of a pre-hospital ECG to facilitate STEMI identification and laboratory activation; and (3) direct transfer by ground transportation to the UFHJ cardiac catheterization laboratory. FMC-to-device (FMC2D), door-to-device (D2D), and transit times, the day of week, time of day, and EMS shift times were recorded, and odds ratio (OR) of achieving FMC2D times was calculated.
  
  
  RESULTS
  FMC2D times were shorter for in-state STEMIs (81 ± 17vs. 87 ± 19 min), but D2D times were similar (37 ± 18vs. 39 ± 21 min). FMC2D ≤ 90 min were achieved in 82.7% in-state STEMIs compared to 52.2% for out-of-state STEMIs (OR = 4.4, 95% CI: 1.24-15.57;P= 0.018). FMC2D times were homogenous after adjusting for weekdayvs. weekend, EMS shift times. Nine patients did not meet FMC2D ≤ 90 min. Six were within 10 min of target; all patient achieved FMC2D ≤ 120 min.
  
  
  CONCLUSIONS
  Guideline-compliant FMC2D ≤ 90 min is achievable for rural STEMI patients within a 50 mile radius of a PCI-capable hospital by use of protocol-driven EMS ground transportation. As all patients achieved a FMC2D time ≤ 120 min, bypass of non-PCI capable hospitals may be reasonable in this situation.
authors.affiliation: Valley Cardiology, Fayetteville, North Carolina, USA.
authors.forename: Charles-Lwanga K
authors.initials: CK
authors.lastname: Bennin
authors.affiliation: Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, Jacksonville, Florida, USA.
authors.forename: Saif
authors.initials: S
authors.lastname: Ibrahim
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic Scottsdale, Arizona, USA.
authors.forename: Farah
authors.initials: F
authors.lastname: Al-Saffar
authors.affiliation: West Valley Medical Group, Caldwell, Idaho, USA.
authors.forename: Lyndon C
authors.initials: LC
authors.lastname: Box
authors.affiliation: Florida Polytechnic University, Lakeland, Florida, USA.
authors.forename: Joel A
authors.initials: JA
authors.lastname: Strom
keywords: Myocardial infarction; Percutaneous coronary intervention; Systems of care