A Regional Prehospital Electrocardiogram Network with a Single Telecardiology “Hub” for Public Emergency Medical Service: Technical Requirements, Logistics, Manpower, and Preliminary Results
Publication: Telemedicine and e-Health
Volume 17, Issue Number 9
Abstract
Background: In patients with a major cardiac event, the first priority is to minimize time-to-treatment. For many patients, the first and fastest contact with the health system is through emergency medical services (EMS). However, delay to treatment is still significant in developed countries, and international guidelines therefore recommend that EMS use prehospital electrocardiogram (ECG). Many communities are implementing prehospital ECG programs, with different technical solutions. Methods: We report on a region-wide prehospital ECG telecardiology program that involved 233,657 patients from all over Apulia (4 million inhabitants), Italy, who called the public regional free EMS telephone number “118.” Prehospital ECG was transmitted by mobile phone to a single regional telecardiology “hub” where a cardiologist available 24/7 promptly reported the ECG, having a briefing with on-scene EMS personnel and EMS district central; patients were then directed to fibrinolysis or primary percutaneous coronary intervention (PCI) as appropriate. Results: Patients were >70 years in 51% of cases, and 55% of prehospital ECGs were unremarkable; the remaining 45% showed signs suggesting acute coronary syndrome (ACS) in 18%, arrhythmias in 20%, and minor findings in 62%. In cases of suspected ACS (chest pain), ECG findings were normal in 77% of patients; 74% of subjects with suspected ACS were screened within 30′ from the onset of symptoms. Conclusions: A regional single telecardiology hub providing prehospital ECG for a sole regional public EMS provides an example of a prehospital ECG network optimizing quality of ECG report and uniformity of EMS assistance in a large region-wide network.
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References
1.
Concannon TWGriffith JLKent DMNormand SLNewhouse JPAtkins JBeshansky JRSelker HP. Elapsed time in emergency medical services for patients with cardiac complaints: Are some patients at greater risk for delay?Circ Cardiovasc Qual Outcomes200929-15. 1. Concannon TW, Griffith JL, Kent DM, Normand SL, Newhouse JP, Atkins J, Beshansky JR, Selker HP. Elapsed time in emergency medical services for patients with cardiac complaints: Are some patients at greater risk for delay? Circ Cardiovasc Qual Outcomes2009;2:9–15.
2.
Perkins-Porras LWhitehead DLStrike PCSteptoe A. Pre-hospital delay in patients with acute coronary syndrome: Factors associated with patient decision time and home-to-hospital delayEur J Cardiovasc Nurs2009826-33. 2. Perkins-Porras L, Whitehead DL, Strike PC, Steptoe A. Pre-hospital delay in patients with acute coronary syndrome: Factors associated with patient decision time and home-to-hospital delay. Eur J Cardiovasc Nurs2009;8:26–33.
3.
Glickman SWCairns CBChen AYPeterson EDRoe MT. Delays in fibrinolysis as primary reperfusion therapy for acute ST-segment elevation myocardial infarctionAm Heart J2010159998-1004. 3. Glickman SW, Cairns CB, Chen AY, Peterson ED, Roe MT. Delays in fibrinolysis as primary reperfusion therapy for acute ST-segment elevation myocardial infarction. Am Heart J2010;159:998–1004.
4.
Saczynski JSYarzebski JLessard DSpencer FAGurwitz JHGore JMGoldberg RJ. Trends in prehospital delay in patients with acute myocardial infarction (from the Worcester Heart Attack Study)Am J Cardiol20081021589-1594. 4. Saczynski JS, Yarzebski J, Lessard D, Spencer FA, Gurwitz JH, Gore JM, Goldberg RJ. Trends in prehospital delay in patients with acute myocardial infarction (from the Worcester Heart Attack Study). Am J Cardiol2008;102:1589–1594.
5.
Goldberg RJSteg PGSadiq IGranger CBJackson EABudaj ABrieger DAvezum AGoodman S. Extent of, and factors associated with, delay to hospital presentation in patients with acute coronary disease (the GRACE registry)Am J Cardiol200289791-796. 5. Goldberg RJ, Steg PG, Sadiq I, Granger CB, Jackson EA, Budaj A, Brieger D, Avezum A, Goodman S. Extent of, and factors associated with, delay to hospital presentation in patients with acute coronary disease (the GRACE registry). Am J Cardiol2002;89:791–796.
6.
Danchin NDurand EBlanchard D. Pre-hospital thrombolysis in perspectiveEur Heart J2008292835-2842. 6. Danchin N, Durand E, Blanchard D. Pre-hospital thrombolysis in perspective. Eur Heart J2008;29:2835–2842.
7.
Danchin NBlanchard DSteg PSauval PHanania GGoldstein PCambou JPGuéret PVaur LBoutalbi YGenès NLablanche JMUSIC 2000 Investigators. Impact of prehospital thrombolysis for acute myocardial infarction on 1-year outcomeCirculation20041101909-1915. 7. Danchin N, Blanchard D, Steg P, Sauval P, Hanania G, Goldstein P, Cambou JP, Guéret P, Vaur L, Boutalbi Y, Genès N, Lablanche JM; USIC 2000 Investigators. Impact of prehospital thrombolysis for acute myocardial infarction on 1-year outcome. Circulation2004;110:1909–1915.
8.
Kalla KChrist GKarnik RMalzer RNorman GPrachar HSchreiber WUnger GGlogar HKaff ALaggner AMaurer GMlczoch JSlany JWeber HHuber KVienna STEMI Registry Group Implementation of guidelines improves the standard of care. The Viennese Registry on Reperfusion Strategies in ST-Elevation Myocardial Infarction (Vienna STEMI Registry)Circulation20061132398-2405. 8. Kalla K, Christ G, Karnik R, Malzer R, Norman G, Prachar H, Schreiber W, Unger G, Glogar H, Kaff A, Laggner A, Maurer G, Mlczoch J, Slany J, Weber H, Huber K; Vienna STEMI Registry Group Implementation of guidelines improves the standard of care. The Viennese Registry on Reperfusion Strategies in ST-Elevation Myocardial Infarction (Vienna STEMI Registry). Circulation2006;113:2398–2405.
9.
Weaver WDCerqueira MHallstrom APLitwin PEMartin JSKudenchuk PJEisenberg M. Prehospital-initiated vs hospital-initiated thrombolytic therapy: The Myocardial Infarction Triage and Intervention TrialJAMA19932701211-1216. 9. Weaver WD, Cerqueira M, Hallstrom AP, Litwin PE, Martin JS, Kudenchuk PJ, Eisenberg M. Prehospital-initiated vs hospital-initiated thrombolytic therapy: The Myocardial Infarction Triage and Intervention Trial. JAMA1993;270:1211–1216.
10.
Foster DBDufendach JHBarkdoll CMMitchell BK. Prehospital recognition of AMI using independent nurse/paramedic 12-lead ECG evaluation: Impact on in-hospital times to thrombolysis in a rural community hospitalAm J Emerg Med19941225-31. 10. Foster DB, Dufendach JH, Barkdoll CM, Mitchell BK. Prehospital recognition of AMI using independent nurse/paramedic 12-lead ECG evaluation: Impact on in-hospital times to thrombolysis in a rural community hospital. Am J Emerg Med1994;12:25–31.
11.
Morrow DAAntman EMSayah ASchuhwerk KCGiugliano RPdeLemos JAWaller MCohen SARosenberg DGCutler SSMcCabe CHWalls RMBraunwald E. Evaluation of the time saved by prehospital initiation of reteplase for ST-elevation myocardial infarction: Results of the Early Retavase-Thrombolysis in Myocardial Infarction (ER-TIMI) 19 trialJ Am Coll Cardiol20024071-77. 11. Morrow DA, Antman EM, Sayah A, Schuhwerk KC, Giugliano RP, deLemos JA, Waller M, Cohen SA, Rosenberg DG, Cutler SS, McCabe CH, Walls RM, Braunwald E. Evaluation of the time saved by prehospital initiation of reteplase for ST-elevation myocardial infarction: Results of the Early Retavase-Thrombolysis in Myocardial Infarction (ER-TIMI) 19 trial. J Am Coll Cardiol2002;40:71–77.
12.
Ferguson JDBrady WJPerron ADKielar NDBenner JPCurrance SBBraithwaite SAufderheide TP. The prehospital 12-lead electrocardiogram: impact on management of the out-of-hospital acute coronary syndrome patientAm J Emerg Med200321136-142. 12. Ferguson JD, Brady WJ, Perron AD, Kielar ND, Benner JP, Currance SB, Braithwaite S, Aufderheide TP. The prehospital 12-lead electrocardiogram: impact on management of the out-of-hospital acute coronary syndrome patient. Am J Emerg Med2003;21:136–142.
13.
Terkelsen CJLassen JFNørgaard BLGerdes JCPoulsen SHBendix KAnkersen JPGøtzsche LBRømer FKNielsen TTAndersen HR. Reduction of treatment delay in patients with ST-elevation myocardial infarction: Impact of pre-hospital diagnosis and direct referral to primary percutaneous coronary interventionEur Heart J200526770-777. 13. Terkelsen CJ, Lassen JF, Nørgaard BL, Gerdes JC, Poulsen SH, Bendix K, Ankersen JP, Gøtzsche LB, Rømer FK, Nielsen TT, Andersen HR. Reduction of treatment delay in patients with ST-elevation myocardial infarction: Impact of pre-hospital diagnosis and direct referral to primary percutaneous coronary intervention. Eur Heart J2005;26:770–777.
14.
Brainard AHRaynovich WTandberg DBedrick EJ. The prehospital 12-lead electrocardiogram's effect on time to initiation of reperfusion therapy: A systematic review and meta-analysis of existing literatureAm J Emerg Med200523351-356. 14. Brainard AH, Raynovich W, Tandberg D, Bedrick EJ. The prehospital 12-lead electrocardiogram's effect on time to initiation of reperfusion therapy: A systematic review and meta-analysis of existing literature. Am J Emerg Med2005;23:351–356.
15.
Brown JPMahmud EDunford JVBen-Yehuda O. Effect of prehospital 12-lead electrocardiogram on activation of the cardiac catheterization laboratory and door-to-balloon time in ST-segment elevation acute myocardial infarctionAm J Cardiol2008101158-161. 15. Brown JP, Mahmud E, Dunford JV, Ben-Yehuda O. Effect of prehospital 12-lead electrocardiogram on activation of the cardiac catheterization laboratory and door-to-balloon time in ST-segment elevation acute myocardial infarction. Am J Cardiol2008;101:158–161.
16.
Curtis JPPortnay ELWang YMcNamara RLHerrin JBradley EHMagid DJBlaney MECanto JGKrumholz HM. The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000–2002: Findings from the National Registry of Myocardial Infarction-4J Am Coll Cardiol2006471544-1552. 16. Curtis JP, Portnay EL, Wang Y, McNamara RL, Herrin J, Bradley EH, Magid DJ, Blaney ME, Canto JG, Krumholz HM. The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000–2002: Findings from the National Registry of Myocardial Infarction-4. J Am Coll Cardiol2006;47:1544–1552.
17.
Gross BWDauterman KWMoran MGKotler TSSchnugg SJRostykus PSRoss AMWeaver WD. An approach to shorten time to infarct artery patency in patients with ST-segment elevation myocardial infarctionAm J Cardiol2007991360-1363. 17. Gross BW, Dauterman KW, Moran MG, Kotler TS, Schnugg SJ, Rostykus PS, Ross AM, Weaver WD. An approach to shorten time to infarct artery patency in patients with ST-segment elevation myocardial infarction. Am J Cardiol2007;99:1360–1363.
18.
Nallamothu BKBradley EHKrumholz HM. Time to treatment in primary percutaneous coronary interventionN Engl J Med20073571631-1638. 18. Nallamothu BK, Bradley EH, Krumholz HM. Time to treatment in primary percutaneous coronary intervention. N Engl J Med2007;357:1631–1638.
19.
Van de Werf FBax JBetriu ABlomstrom-Lundqvist CCrea FFalk VFilippatos GFox KHuber KKastrati ARosengren ASteg PGTubaro MVerheugt FWeidinger FWeis MESC Committee for Practice Guidelines (CPG)Vahanian ACamm JDe Caterina RDean VDickstein KFilippatos GFunck-Brentano CHellemans IKristensen SDMcGregor KSechtem USilber STendera MWidimsky PZamorano JLSilber SAguirre FVAl-Attar NAlegria EAndreotti FBenzer WBreithardt ODanchin NDi Mario CDudek DGulba DHalvorsen SKaufmann PKornowski RLip GYRutten F. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of CardiologyEur Heart J2008292909-2945. 19. Van de Werf F, Bax J, Betriu A, Blomstrom-Lundqvist C, Crea F, Falk V, Filippatos G, Fox K, Huber K, Kastrati A, Rosengren A, Steg PG, Tubaro M, Verheugt F, Weidinger F, Weis M; ESC Committee for Practice Guidelines (CPG), Vahanian A, Camm J, De Caterina R, Dean V, Dickstein K, Filippatos G, Funck-Brentano C, Hellemans I, Kristensen SD, McGregor K, Sechtem U, Silber S, Tendera M, Widimsky P, Zamorano JL, Silber S, Aguirre FV, Al-Attar N, Alegria E, Andreotti F, Benzer W, Breithardt O, Danchin N, Di Mario C, Dudek D, Gulba D, Halvorsen S, Kaufmann P, Kornowski R, Lip GY, Rutten F. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J2008;29:2909–2945.
20.
Antman EMAnbe DTArmstrong PWBates ERGreen LAHand MHochman JSKrumholz HMKushner FGLamas GAMullany CJOrnato JPPearle DLSloan MASmith SC JrAlpert JSAnderson JLFaxon DPFuster VGibbons RJGregoratos GHalperin JLHiratzka LFHunt SAJacobs AK. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction–executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)Circulation2004110588-636. 20. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction–executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation2004;110:588–636.
21.
Ting HHKrumholz HMBradley EHCone DCCurtis JPDrew BJField JMFrench WJGibler WBGoff DCJacobs AKNallamothu BKO'Connor RESchuur JDAmerican Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee; American Heart Association Council on Cardiovascular Nursing; American Heart Association Council on Clinical Cardiology. Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome: A scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical CardiologyCirculation20081181066-1079. 21. Ting HH, Krumholz HM, Bradley EH, Cone DC, Curtis JP, Drew BJ, Field JM, French WJ, Gibler WB, Goff DC, Jacobs AK, Nallamothu BK, O'Connor RE, Schuur JD; American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee; American Heart Association Council on Cardiovascular Nursing; American Heart Association Council on Clinical Cardiology. Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome: A scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology. Circulation2008;118:1066–1079.
22.
Myocardial infarction redefined. A consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarctionEur Heart J2000211502-1513. 22. Myocardial infarction redefined. A consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. Eur Heart J2000;21:1502–1513.
23.
Brunetti NDDe Gennaro LAmodio GDellegrottaglie GPellegrino PLDi Biase MAntonelli G. Telecardiology applied to a region-wide public emergency health care serviceJ Thromb Thrombolysis20092823-30. 23. Brunetti ND, De Gennaro L, Amodio G, Dellegrottaglie G, Pellegrino PL, Di Biase M, Antonelli G. Telecardiology applied to a region-wide public emergency health care service. J Thromb Thrombolysis2009;28:23–30.
24.
Brunetti NDDellegrottaglie GDe Gennaro LAmodio GDi Biase MAntonelli G. Acute myocardial infarction home diagnosis in a region wide telecardiology network for public emergency health care service: An experience from ItalyEur Heart J200627Suppl140abstract. 24. Brunetti ND, Dellegrottaglie G, De Gennaro L, Amodio G, Di Biase M, Antonelli G. Acute myocardial infarction home diagnosis in a region wide telecardiology network for public emergency health care service: An experience from Italy. Eur Heart J 2006;27(Suppl):140 abstract.
25.
Brunetti NDDe Gennaro LAmodio GDellegrottaglie GPellegrino PLDi Biase MAntonelli G. Telecardiology improves quality of diagnosis and reduces delay to treatment in elderly patients with acute myocardial infarction and atypical presentationEur J Cardiovasc Prev Rehabil201017615-620. 25. Brunetti ND, De Gennaro L, Amodio G, Dellegrottaglie G, Pellegrino PL, Di Biase M, Antonelli G. Telecardiology improves quality of diagnosis and reduces delay to treatment in elderly patients with acute myocardial infarction and atypical presentation. Eur J Cardiovasc Prev Rehabil 2010;17:615–620.
26.
Moyer PFeldman JLevine JBeshansky JSelker HPBarnewolt BBrown DCardoza JPGrossman SAJacobs AKerman BJKimmelstiel CLarson RLosordo DPearlmutter MPozner CRamirez ARosenfield KRyan TZane RCannon C. Implications of the mechanical (PCI) vs thrombolytic controversy for ST segment elevation myocardial infarction on the organization of emergency medical services: The Boston EMS experienceCrit Pathol Cardiol2004353-61. 26. Moyer P, Feldman J, Levine J, Beshansky J, Selker HP, Barnewolt B, Brown D, Cardoza JP, Grossman SA, Jacobs A, Kerman BJ, Kimmelstiel C, Larson R, Losordo D, Pearlmutter M, Pozner C, Ramirez A, Rosenfield K, Ryan T, Zane R, Cannon C. Implications of the mechanical (PCI) vs thrombolytic controversy for ST segment elevation myocardial infarction on the organization of emergency medical services: The Boston EMS experience. Crit Pathol Cardiol2004;3:53– 61.
27.
Rokos ICLarson DMHenry TDKoenig WJEckstein MFrench WJGranger CBRoe MT. Rationale for establishing regional ST-elevation myocardial infarction receiving center (SRC) networksAm Heart J2006152661-667. 27. Rokos IC, Larson DM, Henry TD, Koenig WJ, Eckstein M, French WJ, Granger CB, Roe MT. Rationale for establishing regional ST-elevation myocardial infarction receiving center (SRC) networks. Am Heart J2006;152:661– 667.
28.
Jollis JGRoettig MLAluko AOAnstrom KJApplegate RJBabb JDBerger PBBohle DJFletcher SMGarvey JLHathaway WRHoekstra JWKelly RVMaddox WT Jr.Shiber JRValeri FSWatling BAWilson BHGranger CBReperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments (RACE) Investigators. Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarctionJAMA20072982371-2380. 28. Jollis JG, Roettig ML, Aluko AO, Anstrom KJ, Applegate RJ, Babb JD, Berger PB, Bohle DJ, Fletcher SM, Garvey JL, Hathaway WR, Hoekstra JW, Kelly RV, Maddox WT Jr., Shiber JR, Valeri FS, Watling BA, Wilson BH, Granger CB; Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments (RACE) Investigators. Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction. JAMA2007;298:2371–2380.
29.
Le May MRSo DYDionne RGlover CAFroeschl MPWells GADavies RFSherrard HLMaloney JMarquis JFO'Brien ERTrickett JPoirier PRyan SCHa AJoseph PGLabinaz M. A citywide protocol for primary PCI in ST-segment elevation myocardial infarctionN Engl J Med2008358231-240. 29. Le May MR, So DY, Dionne R, Glover CA, Froeschl MP, Wells GA, Davies RF, Sherrard HL, Maloney J, Marquis JF, O'Brien ER, Trickett J, Poirier P, Ryan SC, Ha A, Joseph PG, Labinaz M. A citywide protocol for primary PCI in ST-segment elevation myocardial infarction. N Engl J Med2008;358:231–240.
30.
Ortolani PMarzocchi AMarrozzini CPalmerini TSaia FSerantoni C et al. Clinical impact of direct referral to primary percutaneous coronary intervention following pre-hospital diagnosis of ST-elevation myocardial infarctionEur Heart J2006271550-1557. 30. Ortolani P, Marzocchi A, Marrozzini C, Palmerini T, Saia F, Serantoni C, et al. Clinical impact of direct referral to primary percutaneous coronary intervention following pre-hospital diagnosis of ST-elevation myocardial infarction. Eur Heart J2006;27:1550–1557.
31.
Zanini RRomano MBuffoli FLettieri CBaccaglioni NSchiavone GAroldi MTomasi LKuwornu HIzzo A. Telecardiology in the management of acute myocardial infarction: The experience of the provincial network of MantovaItal Heart J Suppl20056165-171. 31. Zanini R, Romano M, Buffoli F, Lettieri C, Baccaglioni N, Schiavone G, Aroldi M, Tomasi L, Kuwornu H, Izzo A. Telecardiology in the management of acute myocardial infarction: The experience of the provincial network of Mantova. Ital Heart J Suppl2005;6:165–171.
32.
Rathore SSMehta RHWang YRadford MJKrumholz HM. Effects of age on the quality of care provided to older patients with acute myocardial infarctionAm J Med2003114307-315. 32. Rathore SS, Mehta RH, Wang Y, Radford MJ, Krumholz HM. Effects of age on the quality of care provided to older patients with acute myocardial infarction. Am J Med2003;114:307–315.
33.
De Luca GSuryapranata HOttervanger JPAntman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarctionCirculation20041091223-1225. 33. De Luca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction. Circulation2004;109:1223–1225.
34.
Berger PBEllis SGHolmes DR Jr.Granger CBCriger DABetriu A et al. Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction results from the global use of strategies to open occluded arteries in acute coronary syndromes (GUSTO-IIb) trial for the GUSTO-II investigatorsCirculation199910014-20. 34. Berger PB, Ellis SG, Holmes DR Jr., Granger CB, Criger DA, Betriu A, et al. Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction results from the global use of strategies to open occluded arteries in acute coronary syndromes (GUSTO-IIb) trial for the GUSTO-II investigators. Circulation1999;100:14–20.
35.
Vlahaki DFiaani MMilne WK. A door-to-needle time of 30 minutes or less for myocardial infarction thrombolysis is possible in rural emergency departmentsCJEM200810429-433. 35. Vlahaki D, Fiaani M, Milne WK. A door-to-needle time of 30 minutes or less for myocardial infarction thrombolysis is possible in rural emergency departments. CJEM2008;10:429–433.
36.
Nallamothu BKBates ERHerrin JWang YBradley EHKrumholz HMNRMI Investigators. Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States National Registry of Myocardial Infarction (NRMI)-3/4 analysisCirculation200511761-767. 36. Nallamothu BK, Bates ER, Herrin J, Wang Y, Bradley EH, Krumholz HM; NRMI Investigators. Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States National Registry of Myocardial Infarction (NRMI)-3/4 analysis. Circulation2005;11:761–767.
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Copyright 2011, Mary Ann Liebert, Inc.
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Published in print: November 2011
Published online: 28 October 2011
Published ahead of print: 14 September 2011
Accepted: 21 March 2011
Received: 19 March 2011
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