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Craig D Newgard - One of the best experts on this subject based on the ideXlab platform.
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predictive utility of the total glasgow coma scale versus the motor component of the glasgow coma scale for identification of patients with serious traumatic injuries
Annals of Emergency Medicine, 2017Co-Authors: Roger Chou, Annette M Totten, Nancy Carney, Spencer Dandy, Rongwei Fu, Sara Grusing, Miranda Pappas, Ngoc Wasson, Craig D NewgardAbstract:Study objective The motor component of the Glasgow Coma Scale (mGCS) has been proposed as an easier-to-use alternative to the total GCS (tGCS) for Field assessment of trauma patients by emergency medical services. We perform a systematic review and meta-analysis to compare the predictive utility of the tGCS versus the mGCS or Simplified Motor Scale in Field Triage of trauma for identifying patients with adverse outcomes (inhospital mortality or severe brain injury) or who underwent procedures (neurosurgical intervention or emergency intubation) indicating need for high-level trauma care. Methods Ovid MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Health and Psychosocial Instruments, and the Cochrane databases were searched through June 2016 for English-language cohort studies. We included studies that compared the area under the receiver operating characteristic curve (AUROC) of the tGCS versus the mGCS or Simplified Motor Scale assessed in the Field or shortly after arrival in the emergency department for predicting the outcomes described above. Meta-analyses were performed with a random-effects model, and subgroup and sensitivity analyses were conducted. Results We included 18 head-to-head studies of predictive utility (n=1,703,388). For inhospital mortality, the tGCS was associated with slightly greater discrimination than the mGCS (pooled mean difference in [AUROC] 0.015; 95% confidence interval [CI] 0.009 to 0.022; I 2 =85%; 12 studies) or the Simplified Motor Scale (pooled mean difference in AUROC 0.030; 95% CI 0.024 to 0.036; I 2 =0%; 5 studies). The tGCS was also associated with greater discrimination than the mGCS or Simplified Motor Scale for nonmortality outcomes (differences in AUROC from 0.03 to 0.05). Findings were robust in subgroup and sensitivity analyses. Conclusion The tGCS is associated with slightly greater discrimination than the mGCS or Simplified Motor Scale for identifying severe trauma. The small differences in discrimination are likely to be clinically unimportant and could be offset by factors such as convenience and ease of use.
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evaluation of rural vs urban trauma patients served by 9 1 1 emergency medical services
JAMA Surgery, 2017Co-Authors: Craig D Newgard, Eileen M. Bulger, Clay N Mann, Jerris R Hedges, Dagan A Wright, David P Lehrfeld, Carol Shields, Gregory Hoskins, Craig H. WardenAbstract:Importance Despite a large rural US population, there are potential differences between rural and urban regions in the processes and outcomes following trauma. Objectives To describe and evaluate rural vs urban processes of care, injury severity, and mortality among injured patients served by 9-1-1 emergency medical services (EMS). Design, Setting, and Participants This was a preplanned secondary analysis of a prospective cohort enrolled from January 1 through December 31, 2011, and followed up through hospitalization. The study included 44 EMS agencies transporting to 28 hospitals in 2 rural and 5 urban counties in Oregon and Washington. A population-based, consecutive sample of 67 047 injured children and adults served by EMS (1971 rural and 65 076 urban) was enrolled. Among the 53 487 patients transported by EMS, a stratified probability sample of 17 633 patients (1438 rural and 16 195 urban) was created to track hospital outcomes (78.9% with in-hospital follow-up). Data analysis was performed from June 12, 2015, to May 20, 2016. Exposures Rural was defined at the county level by 60 minutes or more driving proximity to the nearest level I or II trauma center and/or rural designation in the Centers for Medicare & Medicaid Services ambulance fee schedule by zip code. Main Outcomes and Measures Mortality (out-of-hospital and in-hospital), need for early critical resources, and transfer rates. Results Of the 53 487 injured patients transported by EMS (17 633 patients in the probability sample), 27 535 were women (51.5%); mean (SD) age was 51.6 (26.1) years. Rural vs urban sensitivity of Field Triage for identifying patients requiring early critical resources was 65.2% vs 80.5%, and only 29.4% of rural patients needing critical resources were initially transported to major trauma centers vs 88.7% of urban patients. After accounting for transfers, 39.8% of rural patients requiring critical resources were cared for in major trauma centers vs 88.7% of urban patients. Overall mortality did not differ between rural and urban regions (1.44% vs 0.89%; P = .09); however, 89.6% of rural deaths occurred within 24 hours compared with 64% of urban deaths. Rural regions had higher transfer rates (3.2% vs 2.7%) and longer transfer distances (median, 97.4 km; interquartile range [IQR], 51.7-394.5 km; range, 47.8-398.6 km vs 22.5 km; IQR, 11.6-24.6 km; range, 3.5-97.4 km). Conclusions and Relevance Most high-risk trauma patients injured in rural areas were cared for outside of major trauma centers and most rural trauma deaths occurred early, although overall mortality did not differ between regions. There are opportunities for improved timeliness and access to major trauma care among patients injured in rural regions.
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cost effectiveness of Field trauma Triage among injured adults served by emergency medical services
Journal of The American College of Surgeons, 2016Co-Authors: Craig D Newgard, Mohamud Daya, Renee Y. Hsia, James F. Holmes, Clay N Mann, Zhuo Yang, Daniel K Nishijima, John K Mcconnell, Stacy A Trent, Thomas D ReaAbstract:Background The American College of Surgeons Committee on Trauma sets national targets for the accuracy of Field trauma Triage at ≥95% sensitivity and ≥65% specificity, yet the cost-effectiveness of realizing these goals is unknown. We evaluated the cost-effectiveness of current Field trauma Triage practices compared with Triage strategies consistent with the national targets. Study Design This was a cost-effectiveness analysis using data from 79,937 injured adults transported by 48 emergency medical services agencies to 105 trauma and nontrauma hospitals in 6 regions of the western United States from 2006 through 2008. Incremental differences in survival, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio (costs per QALY gained) were estimated for each Triage strategy during a 1-year and lifetime horizon using a decision analytic Markov model. We considered an incremental cost-effectiveness ratio threshold of Results For these 6 regions, a high-sensitivity Triage strategy consistent with national trauma policy (sensitivity 98.6%, specificity 17.1%) would cost $1,317,333 per QALY gained, and current Triage practices (sensitivity 87.2%, specificity 64.0%) cost $88,000 per QALY gained, compared with a moderate sensitivity strategy (sensitivity 71.2%, specificity 66.5%). Refining emergency medical services transport patterns by Triage status improved cost-effectiveness. At the trauma-system level, a high-sensitivity Triage strategy would save 3.7 additional lives per year at a 1-year cost of $8.78 million, and a moderate sensitivity approach would cost 5.2 additional lives and save $781,616 each year. Conclusions A high-sensitivity approach to Field Triage consistent with national trauma policy is not cost-effective. The most cost-effective approach to Field Triage appears closely tied to Triage specificity and adherence to Triage-based emergency medical services transport practices.
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evaluating the use of existing data sources probabilistic linkage and multiple imputation to build population based injury databases across phases of trauma care
Academic Emergency Medicine, 2012Co-Authors: Craig D Newgard, Renee Y. Hsia, James F. Holmes, Kristan Staudenmayer, Ewen N Wang, Clay N Mann, Susan Malveau, Nathan Kuppermann, Jason S Haukoos, Eileen M. BulgerAbstract:Injury continues to be a major cause of death and disability, particularly among the young.1,2 While the development of trauma centers, trauma systems, injury prevention programs, and public policy have resulted in many strides toward reducing the burden of injury, much work remains. Integral to understanding and further reducing the burden of injury is the ability to measure how injury relates to meaningful health outcomes across broad populations and different phases of care. Trauma registries have traditionally provided the bulk of available injury data. However, trauma registries preferentially target more seriously injured patients treated at trauma centers, are not population-based, and are typically limited to in-hospital outcomes. There is a growing need for broad population-based injury data that effectively span multiple phases of care (out-of-hospital, in-hospital, and postdischarge); include patients with minor and severe injuries; and are not limited by cost, resource, and confidentiality constraints. Such population-based data may be used for trauma quality assurance, improving the effectiveness of Field Triage protocols and early treatment interventions, and evaluating the outcomes of injured patients not treated at trauma centers and falling outside of traditional quality assurance data sources (e.g., trauma registries). The increasing availability of electronic data combined with certain analytic methods (probabilistic linkage3,4 and multiple imputation5) provide an opportunity to create such unique data resources. Probabilistic linkage is a method for matching disparate datasets when a unique identifier is not available and has been used to match emergency medical systems (EMS) records to hospital outcomes6,7 and validated among injured patients.8 Due to match rates (the proportion of matches among eligible patients) typically less than 100%, and the substantive portion of missing values inherent in EMS and trauma data sources, missing data have been another obstacle in developing population-based injury databases. Handling missing values inappropriately can generate bias, reduce sample size, and lessen study power.9–14 Multiple imputation can effectively mitigate these limitations, provided that certain assumptions are met. We are unaware of any studies evaluating the combined use of probabilistic linkage and multiple imputation in the construction of large population-based databases. While the use and integration of electronic health information is being actively promoted in the United States,15 there is a need for additional literature detailing the methods to effectively link such records across multiple phases of care between different agencies and institutions and appropriately handle missing values. In this article, we describe the methods and evaluate the use of existing data files, probabilistic linkage, and multiple imputation in constructing large population-based injury databases matched to outcomes under a variety of conditions across seven regions in the western United States.
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a multisite assessment of the american college of surgeons committee on trauma Field Triage decision scheme for identifying seriously injured children and adults
Journal of The American College of Surgeons, 2011Co-Authors: Craig D Newgard, Dana Zive, Eileen M. Bulger, Renee Y. Hsia, James F. Holmes, Kristan Staudenmayer, Michael Liao, Ewen N Wang, Ross J Fleischman, Clay N MannAbstract:Background The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated Field trauma Triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ≥ 16) in a large and diverse multisite cohort. Study Design This was a retrospective cohort study of injured children and adults transported by 94 emergency medical services (EMS) agencies to 122 hospitals in 7 regions of the Western US from 2006 through 2008. Patients who met any of the Field trauma Triage criteria (per EMS personnel) were considered Triage positive. Hospital outcomes measures were probabilistically linked to EMS records through trauma registries, state discharge data, and emergency department data. The primary outcome defining a "major trauma patient" was ISS ≥ 16. Results There were 122,345 injured patients evaluated and transported by EMS over the 3-year period, 34.5% of whom met at least 1 Triage criterion and 5.8% had ISS ≥ 16. The overall sensitivity and specificity of the criteria for identifying major trauma patients were 85.8% (95% CI 85.0% to 86.6%) and 68.7% (95% CI 68.4% to 68.9%), respectively. Triage sensitivity and specificity, respectively, differed by age: 84.1% and 66.4% (0 to 17 years); 89.5% and 64.3% (18 to 54 years); and 79.9% and 75.4% (≥55 years). Evaluating the diagnostic value of Triage by hospital destination (transport to Level I/II trauma centers) did not substantially improve these findings. Conclusions The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.
Jens Flensted Lassen - One of the best experts on this subject based on the ideXlab platform.
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the divergence between european stemi guidelines and evidence a potential threat to optimising reperfusion therapy for patients with st elevation myocardial infarction
Heart, 2013Co-Authors: Christian Juhl Terkelsen, Jens Flensted Lassen, Duane S Pinto, Holger Thiele, Peter Clemmensen, Kjell Nikus, David Hildicksmith, Evald Hoj Christiansen, Jens Aaroe, Hanshenrik Tilsted HansenAbstract:The 2012 European Society of Cardiology (ESC) ST-Elevation Myocardial Infarction (STEMI) guideline acknowledges that STEMI patients should receive reperfusion therapy as soon as possible, and that prehospital fibrinolysis or Field-Triage directly to Primary Percutaneous Coronary Intervention (PPCI) centres is the preferred reperfusion strategy.1 However, when recommending fibrinolytic therapy (FT) within 30 min from First Medical Contact (FMC), if PPCI cannot be performed ‘within 60 min of FMC in patients presenting early, with a large amount of myocardium at risk’, the guidelines imply that only 30 min extra may be expended to perform PPCI instead of administering FT (‘PCI-related delay’) (figure 1). Figure 1 Various delays when treating patients with ST-Elevation Myocardial Infarction (STEMI) with fibrinolysis or primary percutaneous coronary intervention (PPCI). ‘Healthcare system delay’ is the total delay from emergency medical service (EMS) call to PPCI. ‘PCI-related delay’ is the extra delay that one may use to perform PPCI instead of administering fibrinolysis and still achieve a mortality benefit from PPCI. First Medical Contact (either EMS call, EMS arrival on scene, or arrival at hospital according to regional STEMI system of care). Throughout the years, successive guidelines have mistakenly equated ‘PCI-related delay’ and ‘FMC to PPCI’ (the total delay from FMC to PPCI) (figure 1). This error persists in the recently updated ESC guideline.1 Clarification of this distinction is of paramount importance because of the suggested reduction in the ‘window of opportunity for PPCI’, a suggestion not clearly supported by evidence, which has significant public health implications. In paragraph 3.5.2, the ESC STEMI guideline references a registry analysis from the National Registry of Myocardial Infarction (NRMI),2 concluding: ‘primary PCI (wire passage) should be performed within 90 min after FMC in all cases. In patients presenting early, with a large amount of myocardium at risk, the delay should be shorter (<60 min).’ The NRMI …
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primary percutaneous coronary intervention as a national reperfusion strategy in patients with st segment elevation myocardial infarction
Circulation-cardiovascular Interventions, 2011Co-Authors: Christian Juhl Terkelsen, Lisette Okkels Jensen, Hans H Tilsted, Per Thaysen, Jan Ravkilde, Soren Paaske Johnsen, Sven Trautner, Henning Rud Andersen, Leif Thuesen, Jens Flensted LassenAbstract:Background—In Denmark, primary percutaneous coronary intervention (PPCI) was chosen as a national reperfusion strategy for patients with ST-segment elevation myocardial infarction in 2003. This study describes the temporal implementation of PPCI in Western Denmark, the gradual introduction of Field Triage for PPCI (patients rerouted from the scene of the event directly to the invasive center), and the associated outcome. Methods and Results—The study population comprised 9514 patients treated with PPCI from 1999 to 2009 with symptom duration ≤12 hours and either a delay from the emergency medical service (EMS) call to PPCI (healthcare system delay) of ≤6 hours or as self-presenters. The median follow-up time was 3.7 years. The number of patients treated with PPCI increased from 190 in 1999 to 1212 in 2009. Among patients transported by the EMS from the scene of the event, the proportion who were Field Triaged directly to a PCI center increased from 33% (34/103) to 72% (616/851, P<0.001). Patients who were...
Christian Juhl Terkelsen - One of the best experts on this subject based on the ideXlab platform.
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the divergence between european stemi guidelines and evidence a potential threat to optimising reperfusion therapy for patients with st elevation myocardial infarction
Heart, 2013Co-Authors: Christian Juhl Terkelsen, Jens Flensted Lassen, Duane S Pinto, Holger Thiele, Peter Clemmensen, Kjell Nikus, David Hildicksmith, Evald Hoj Christiansen, Jens Aaroe, Hanshenrik Tilsted HansenAbstract:The 2012 European Society of Cardiology (ESC) ST-Elevation Myocardial Infarction (STEMI) guideline acknowledges that STEMI patients should receive reperfusion therapy as soon as possible, and that prehospital fibrinolysis or Field-Triage directly to Primary Percutaneous Coronary Intervention (PPCI) centres is the preferred reperfusion strategy.1 However, when recommending fibrinolytic therapy (FT) within 30 min from First Medical Contact (FMC), if PPCI cannot be performed ‘within 60 min of FMC in patients presenting early, with a large amount of myocardium at risk’, the guidelines imply that only 30 min extra may be expended to perform PPCI instead of administering FT (‘PCI-related delay’) (figure 1). Figure 1 Various delays when treating patients with ST-Elevation Myocardial Infarction (STEMI) with fibrinolysis or primary percutaneous coronary intervention (PPCI). ‘Healthcare system delay’ is the total delay from emergency medical service (EMS) call to PPCI. ‘PCI-related delay’ is the extra delay that one may use to perform PPCI instead of administering fibrinolysis and still achieve a mortality benefit from PPCI. First Medical Contact (either EMS call, EMS arrival on scene, or arrival at hospital according to regional STEMI system of care). Throughout the years, successive guidelines have mistakenly equated ‘PCI-related delay’ and ‘FMC to PPCI’ (the total delay from FMC to PPCI) (figure 1). This error persists in the recently updated ESC guideline.1 Clarification of this distinction is of paramount importance because of the suggested reduction in the ‘window of opportunity for PPCI’, a suggestion not clearly supported by evidence, which has significant public health implications. In paragraph 3.5.2, the ESC STEMI guideline references a registry analysis from the National Registry of Myocardial Infarction (NRMI),2 concluding: ‘primary PCI (wire passage) should be performed within 90 min after FMC in all cases. In patients presenting early, with a large amount of myocardium at risk, the delay should be shorter (<60 min).’ The NRMI …
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primary percutaneous coronary intervention as a national reperfusion strategy in patients with st segment elevation myocardial infarction
Circulation-cardiovascular Interventions, 2011Co-Authors: Christian Juhl Terkelsen, Lisette Okkels Jensen, Hans H Tilsted, Per Thaysen, Jan Ravkilde, Soren Paaske Johnsen, Sven Trautner, Henning Rud Andersen, Leif Thuesen, Jens Flensted LassenAbstract:Background—In Denmark, primary percutaneous coronary intervention (PPCI) was chosen as a national reperfusion strategy for patients with ST-segment elevation myocardial infarction in 2003. This study describes the temporal implementation of PPCI in Western Denmark, the gradual introduction of Field Triage for PPCI (patients rerouted from the scene of the event directly to the invasive center), and the associated outcome. Methods and Results—The study population comprised 9514 patients treated with PPCI from 1999 to 2009 with symptom duration ≤12 hours and either a delay from the emergency medical service (EMS) call to PPCI (healthcare system delay) of ≤6 hours or as self-presenters. The median follow-up time was 3.7 years. The number of patients treated with PPCI increased from 190 in 1999 to 1212 in 2009. Among patients transported by the EMS from the scene of the event, the proportion who were Field Triaged directly to a PCI center increased from 33% (34/103) to 72% (616/851, P<0.001). Patients who were...
Koen W. W. Lansink - One of the best experts on this subject based on the ideXlab platform.
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The impact of the Trauma Triage App on pre-hospital trauma Triage: design and protocol of the stepped-wedge, cluster-randomized TESLA trial.
Diagnostic and Prognostic Research, 2020Co-Authors: Rogier Van Der Sluijs, Koen W. W. Lansink, Job F Waalwijk, Dennis Den Hartog, Audrey A.a. Fiddelers, Johannes B. Reitsma, Miranda J.m. Dirx, Silvia M. A. A. Evers, J. Carel Goslings, W. Margreet HoogeveenAbstract:Field Triage of trauma patients is crucial to get the right patient to the right hospital within a particular time frame. Minimization of underTriage, overTriage, and interhospital transfer rates could substantially reduce mortality rates, life-long disabilities, and costs. Identification of patients in need of specialized trauma care is predominantly based on the judgment of Emergency Medical Services professionals and a pre-hospital Triage protocol. The Trauma Triage App is a smartphone application that includes a prediction model to aid Emergency Medical Services professionals in the identification of patients in need of specialized trauma care. The aim of this trial is to assess the impact of this new digital approach to Field Triage on the primary endpoint underTriage. The Trauma Triage using Supervised Learning Algorithms (TESLA) trial is a stepped-wedge cluster-randomized controlled trial with eight clusters defined as Emergency Medical Services regions. These clusters are an integral part of five inclusive trauma regions. Injured patients, evaluated on-scene by an Emergency Medical Services professional, suspected of moderate to severe injuries, will be assessed for eligibility. This unidirectional crossover trial will start with a baseline period in which the default pre-hospital Triage protocol is used, after which all clusters gradually implement the Trauma Triage App as an add-on to the existing Triage protocol. The primary endpoint is underTriage on patient and cluster level and is defined as the transportation of a severely injured patient (Injury Severity Score ≥ 16) to a lower-level trauma center. Secondary endpoints include overTriage, hospital resource use, and a cost-utility analysis. The TESLA trial will assess the impact of the Trauma Triage App in clinical practice. This novel approach to Field Triage will give new and previously undiscovered insights into several isolated components of the diagnostic strategy to get the right trauma patient to the right hospital. The stepped-wedge design allows for within and between cluster comparisons. Netherlands Trial Register, NTR7243. Registered 30 May 2018, https://www.trialregister.nl/trial/7038.
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Accuracy of the Field Triage protocol in selecting severely injured patients after high energy trauma
Injury, 2014Co-Authors: J.j.e.m. Van Laarhoven, Mark Van Heijl, Koen W. W. Lansink, Rob A. Lichtveld, Luke P. H. LeenenAbstract:Abstract Background For optimal treatment of trauma patients it is of great importance to identify patients who are at risk for severe injuries. The Dutch Field Triage protocol for trauma patients, the LPA (National Protocol of Ambulance Services), is designed to get the right patient, in the right time, to the right hospital. Purpose of this study was to determine diagnostic accuracy and compliance of this Triage protocol. Study design Triage criteria were categorised into physiological condition (P), mechanism of trauma (M) and injury type (I). A retrospective analysis of prospectively collected data of all high-energy trauma patients from 2008 to 2011 in the region Central Netherlands is performed. Diagnostic parameters (sensitivity, specificity, negative predictive value, positive predictive value) of the Field Triage protocol for selecting severely injured patients were calculated including rates of under- and overTriage. UnderTriage was defined as the proportion of severely injured patients (Injury Severity Score (ISS) ≥ 16) who were transported to a level two or three trauma care centre. OverTriage was defined as the proportion of non-severely injured patients (ISS Results Overall sensitivity and specificity of the Field Triage protocol was 89.1% (95% confidence interval (CI) 84.4–92.6) and 60.5% (95% CI 57.9–63.1), respectively. The overall rate of underTriage was 10.9% (95%CI 7.4–15.7) and the overall rate of overTriage was 39.5% (95%CI 36.9–42.1). These rates were 16.5% and 37.7%, respectively for patients with M+I−P−. Compliance to the Triage protocol for patients with M+I−P− was 78.7%. Furthermore, compliance in patients with either a positive I+ or positive P+ was 91.2%. Conclusion The overall rate of underTriage (10.8%) was mainly influenced by a high rate of underTriage in the group of patients with only a positive mechanism criterion, therefore showing low diagnostic accuracy in selecting severely injured patients. As a consequence these patients with severe injury are undetected using the current Triage protocol. As it has been shown that severely injured patients have better outcome in level one trauma care centres further optimisation of this protocol aiming at lowering underTriage is therefore essential, preferably without incrementing overTriage too much.
Peer Grande - One of the best experts on this subject based on the ideXlab platform.
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reperfusion delay in patients treated with primary percutaneous coronary intervention insight from a real world danish st segment elevation myocardial infarction population in the era of telemedicine
European heart journal. Acute cardiovascular care, 2012Co-Authors: Mikkel Malby Schoos, Maria Sejersten, Anders Hvelplund, Mette Madsen, Jacob Lonborg, Jacob Steinmetz, Philip Michael Treschow, Frants Pedersen, Erik Jorgensen, Peer GrandeAbstract:Background:Reperfusion delay in ST-segment elevation myocardial infarction (STEMI) predicts adverse outcome. We evaluated time from alarm call (system delay) and time from first medical contact (PCI-related delay), where fibrinolysis could be initiated, to balloon inflation in a pre-hospital organization with tele-transmitted electrocardiograms, Field Triage and direct transfer to a 24/7 primary percutaneous coronary intervention (PPCI) center.Methods and results:This was a single center cohort study with long-term follow-up in 472 patients. The PPCI center registry was linked by person identification number to emergency medical services (EMS) and National Board of Health databases in the period of 2005–2008. Patients were stratified according to transfer distances to PPCI into zone 1 (0–25 km), zone 2 (65–100 km) and zone 3 (101–185 km) and according to referral by pre-hospital Triage. System delay was 86 minutes (interquartile range (IQR) 72–113) in zone 1, 133 (116–180) in zone 2 and 173 (145–215) in z...