Nationwide Improvement of Door-to-Balloon Times in Patients With Acute ST-Segment Elevation Myocardial Infarction Requiring Primary Percutaneous Coronary Intervention With Out-of-Hospital 12-Lead ECG Recording and Transmission

Development of prehospital emergency care in Singapore

This review paper describes the development of the pre-hospital system in Singapore from the pre-war days. Every country's prehospital community needs a deep understanding of how they developed over the years, factors that played a part, and the aspirations their community and government have set for this. This can guide future evolution of the services to ensure that care provided is relevant, applicable and in keeping with the community's needs. Countries with similar contextual circumstances, but at a different stage of development of their PECs, may learn from these.

Identifying and Solving Gaps in Pre- and In-Hospital Acute Myocardial Infarction Care in Asia-Pacific Countries

Acute myocardial infarction (AMI) is a major cause of morbidity and mortality in the Asia-Pacific region, and mortality rates differ between countries in the region. Systems of care have been shown to play a major role in determining AMI outcomes, and this review aims to highlight pre-hospital and in-hospital system deficiencies and suggest possible improvements to enhance quality of care, focusing on Korea, Japan, Singapore and Malaysia as representative countries. Time to first medical contact can be shortened by improving patient awareness of AMI symptoms and the need to activate emergency medical services (EMS), as well as by developing robust, well-coordinated and centralized EMS systems. Additionally, performing and transmitting pre-hospital electrocardiograms, algorithmically identifying patients with high risk AMI and developing hospital networks that appropriately divert such patients to percutaneous coronary intervention-capable hospitals have been shown to be beneficial. Within the hospital environment, developing and following clinical practice guidelines ensures that treatment plans can be standardised, whilst integrated care pathways can aid in coordinating care within the healthcare institution and can guide care even after discharge. Prescription of guideline directed medical therapy for secondary prevention and patient compliance to medications can be further optimised. Finally, the authors advocate for the establishment of more regional, national and international AMI registries for the formal collection of data to facilitate audit and clinical improvement.

Pro-Con Debate: Are Patients With Coronary Stents Suitable for Free-Standing Ambulatory Surgery Centers?

With increasing implantation of coronary artery stents over the past 2 decades, it is inevitable that anesthesiologists practicing in the outpatient setting will need to determine whether these patients are suitable for procedures at a free-standing ambulatory surgery center (ASC). Appropriate selection of patients with coronary artery stents for a procedure in an ASC requires consideration of factors that affect the balance between the risk of stent thrombosis due to interruption of antiplatelet therapy and the thrombogenic effects of surgery, and the risk of perioperative bleeding complications that may occur if antiplatelet therapy is continued. Thus, periprocedure care of these patients presents unique challenges, particularly for extensive surgical procedures that are increasingly scheduled for free-standing ASCs, where consultation and ancillary services, as well as access to percutaneous cardiac interventions, may not be readily available. Therefore, the suitability of the ambulatory setting for this patient population remains highly controversial. In this Pro-Con commentary, we discuss the arguments for and against scheduling patients with coronary artery stents in free-standing ASCs.

Improved door-to-balloon time for primary percutaneous coronary intervention for patients conveyed via emergency ambulance service

INTRODUCTION

Early reperfusion of ST-segment elevation myocardial infarction (STEMI) results in better outcomes. Interventions that have resulted in shorter door-to-balloon (DTB) time include prehospital cardiovascular laboratory activation and prehospital electrocardiogram (ECG) transmission, which are only available for patients who arrive via emergency ambulances. We assessed the impact of mode of transport on DTB time in a single tertiary institution and evaluated the factors that affected various components of DTB time.

METHODS

We conducted a retrospective cohort study using registry data of patients diagnosed with STEMI in the emergency department (ED) who underwent primary percutaneous coronary intervention. We compared patients who arrived by emergency ambulances with those who came via their own transport. The primary study end point was DTB, defined as the earliest time a patient arrived in the ED to balloon inflation. As deidentified data was used, ethics review was waived.

RESULTS

A total of 321 patients were included for analysis after excluding 7 with missing data. The mean age was 61.4±11.4 years old with 49 (15.3%) females. Ninety-nine (30.8%) patients arrived by emergency ambulance. The median DTB time was shorter for patients arriving by ambulance versus own transport (52min, interquartile range [IQR] 45-61 vs 67min, IQR 59-74; P<0.001), with shorter door-to-ECG and door-to-activation time.

CONCLUSION

Arrival via emergency ambulance was associated with a decreased DTB for STEMI patients compared to arriving via own transport. There is a need for public education to increase the usage of emergency ambulances for suspected heart attacks to improve outcomes.

Clinical significance of prehospital 12-lead electrocardiography in patients with ST-segment elevation myocardial infarction presenting with syncope: from a multicenter observational registry (K-ACTIVE study)

Patients with acute myocardial infarction (AMI) presenting with syncope have poor clinical outcomes partly due to a delay in the diagnosis. Although the impact of prehospital 12-lead electrocardiography (PHECG) on the reduction of first medical contact (FMC)-to-device time and subsequent adverse clinical events in patients with AMI has been demonstrated, the impact of PHECG for the patients presenting with syncope remains to be elucidated. This study aimed to explore the impact of PHECG on 30-day mortality in patients with ST-segment elevation myocardial infarction (STEMI) presenting with syncope. From a cohort of multi-center registry [Kanagawa-ACuTe cardIoVascular rEgistry (K-ACTIVE)], a total of 90 consecutive patients with STEMI presenting with syncope were included. The 30-day mortality were compared between patients with PHECG (PHECG group, n = 25) and those without PHECG (non-PHECG group, n = 65). There was no significant difference in the baseline clinical characteristics between the 2 groups. FMC-to-device time was significantly shorter in the PHECG group than in the non-PHECG group (122 [86, 128] vs. 131 [102, 153] min, p = 0.03) due to the shorter door-to-device time. Thirty-day mortality was significantly lower in the PHECG group than in the non-PHECG group (16.0 vs. 44.6%, p = 0.03). In conclusion, PHECG was associated with shorter FMC-to-device time and lower 30-day mortality in patients with STEMI presenting with syncope.

Prehospital management of patients with suspected acute coronary syndrome : Real world experience reflecting current guidelines

Background

In case of suspected acute coronary syndrome (ACS), international guidelines recommend to obtain a 12-lead ECG as soon as possible after first medical contact, to administrate platelet aggregation inhibitors and antithrombins, and to transfer the patient as quickly as possible to an emergency department.

Methods

A German emergency care service database was retrospectively analysed from 2014 to 2016. Data were tested for normal distribution and the Mann–Whitney test was used for statistical analysis. Results are presented as medians (IQR).

Results

A total of 1424 patients with suspected ACS were included in the present analysis. A 12-lead ECG was documented in 96% of patients (n = 1369). The prehospital incidence of ST-segment elevation myocardial infarction (STEMI) was 18% (n = 250). In 981 patients (69%), acetylsalicylic acid (ASA), unfractionated heparin (UFH), or ASA and UFH was given. Time in prehospital care differed significantly between non-STEMI (NSTEMI) ACS (37 [IQR 30, 44] min) and STEMI patients (33 [IQR 26, 40] min, n = 1395, p < 0.0001). Most of NSTEMI ACS and STEMI patients were brought to the emergency care unit, while 30% of STEMI patients were directly handed over to a cardiac catheterization laboratory.

Conclusions

Prehospital ECG helps to identify patients with STEMI, which occurs in 18% of suspected ACS. Patients without ST-elevations suffered from longer prehospital care times. Thus, it is tempting to speculate that ST-elevations in patients prompt prehospital medical teams to act more efficiently while the absence of ST-elevations even in patients with suspected ACS might cause unintended delays. Moreover, this analysis suggests the need for further efforts to make the cardiac catheterization laboratory the standard hand-over location for all STEMI patients.

Primary Percutaneous Coronary Intervention Facility Hospitals and Easy Access Can Affect the Outcomes of ST-Segment Elevation Myocardial Infarction Patients

BACKGROUND

The reperfusion therapy using primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction (STEMI) is known to give a better result than fibrinolytic therapy. The fast access to PPCI will improve hospital outcome. We believe that patient access to PPCI facility would have improved due to enhanced public awareness and expanding evidenced-based health provision.

METHODS

This is a single-center retrospective study to analyze and compare data for STEMI patients. Patients were transferred to our hospital during the year 2010. Group l comprised 223 patients. Group 2 comprised 288 patients. Group 2 patients were those treated between August 2014 and August 2015. We compared their demographic and baseline characteristics, patients' access to the hospital, reasons for no access, and hospital mortality for the two groups.

RESULTS

Among the 288 patients in Group 2, 247 patients (85%) were males with an average age of 57 years, 49% were diabetics, 48% were hypertensive, 48% were smokers, and 27% were obese. These were not different in Group 1. In Group 2, 164 patients (57%) only had access to PPCI compared to 56% in Group 1 (P = 0.536-NS). In G2, the main reasons for no PPCI were late presentation in 47% versus 53% in Group 1; P = 0.34 NS. In Group 2, 27% were due to thrombolysis versus 17% in Group 1 (P = 0.11 NS). Hospital mortality in Group 2 was 4% in those treated with PPCI compared to 2.3% in Group 1 (P = 0.522-NS). Mortality in patients who did not receive PPCI in Group 2 was 8% compared to 11.3% in Group 1 (P = 0.49-NS). Females in Group 2 have about 3 times higher mortality. Patients treated for STEMI in the last 12 months at King Abdulaziz Cardiac Center still have relatively low access to PPCI due mainly to persistent pattern of late presentation and prior thrombolysis, which reflect apparent lack of direct access to hospitals with PPCI facilities.

CONCLUSION

Comparing the two periods, there was no change in cardiology practice. The low access to PPCI was mainly due to late presentation and prior thrombolysis. Hospital mortality rate for patients treated with PPCI remained low during the two era. This seemingly relates to both lack of public awareness and health provision factors in PPCI organizations.

Community-Based Pre-Hospital Electrocardiogram Transmission Program for Reducing Systemic Time Delay in Acute ST-Segment Elevation Myocardial Infarction

Background and Objectives

In acute ST-segment elevation myocardial infarction (STEMI), on-site transmission of electrocardiogram (ECG) has been shown to reduce systemic time delay to reperfusion and improve outcomes. However, it has not been adopted in community-based emergency transport system in Korea.

Methods

Busan Regional Cardio-cerebrovascular Center and Busan Metropolitan City Fire and Safety Headquarters (BMFSH) jointly developed and conducted a pre-hospital ECG transmission program. Seven tertiary hospitals and 22 safety stations of BMFSH participated. Systemic time delay to reperfusion of STEMI patients in the program was compared with that of 95 patients transported by 119 emergency medical system (EMS) before the program was implemented.

Results

During the study period, 289 ECG transmissions were made by 119 EMS personnel, executed within 5 minutes in 88.1% of cases. Of these, 42 ECGs were interpreted as ST-segment elevation. Final diagnosis of STEMI was made in 20 patients who underwent primary percutaneous coronary intervention. With the program, systemic time delay to reperfusion was significantly reduced (median [interquartile range; IQR], 76.0 [62.2–98.7] vs. 90.0 [75.0–112.0], p<0.01). Significant reduction of door-to-balloon time was also observed (median [IQR], 45.0 [34.0–69.5] vs. 58.0 [51.0–68.0], p=0.03). The proportion of patients with systemic time delay shorter than 90 minutes rose (51.6% vs. 75.0%, p=0.08) with pre-hospital ECG transmission.

Conclusions

We developed and implemented a community-based pre-hospital ECG transmission program for expeditious triage of STEMI patients. Significant reductions of systemic time delay and door-to-balloon time were observed. The expanded use of pre-hospital ECG transmission should be encouraged to realize the full potential of this program.

Assessment of diagnostic accuracy of SanketLife - A wireless, pocket-sized ECG biosensor, in comparison to standard 12 lead ECG in the detection of cardiovascular diseases in a tertiary care setting

Background

The SanketLife is a low cost, portable, pocket sized 12 lead ECG mechanised by SanketLife app running on compatible iOS and Android phones that connect wirelessly via Bluetooth technology to the device.

Objective

The current study was conducted to assess the diagnostic accuracy of SanketLife ECG in comparison to standard 12 lead ECG (GE-2000) in detection of cardiovascular diseases.

Research design and methods

This was a prospective diagnostic test accuracy trial conducted in outpatient settings of a tertiary cardiac care centre in India. A total of 100 patients, attended cardiology OPD, were included in the study. Consecutive ECGs were taken by 12 lead standard ECG as well as by SanketLife ECG. Diagnostic accuracy variables such as sensitivity, specificity, negative and positive predictive value, negative and positive likelihood ratios were estimated. Ethical permission was taken from the Institutional ethical committee.

Results & conclusion

The analysis showed a high degree of agreement and accuracy of SanketLife in detecting major cardiovascular conditions (Major Minnesota codes) such as Left and right bundle branch block, ST-segment elevation and ST-segment depression, AV conduction block. SanketLife showed high sensitivity (98.15%) and specificity (100%) in diagnosing major cardiovascular conditions.

ECG pre-hospital teletransmission by emergency teams staffed with an emergency physician and paramedics and its impact on transportation and hospital admission

Electrocardiography (ECG) is essential to detect and diagnose life threatening cardiac conditions and to determine further treatment. Correct interpretation of an ECG can be challenging, especially in the out-of-hospital setting and by less experienced emergency team members.The aim of this study was to compare the rate of ECG transmission from an out-of-hospital emergency scene to an in-hospital cardiologist on call in EMS-B and EMS-S providers and its impact on direct transportation to a cardiac catheterization laboratory and hospital admission.The study was designed as an observational study. Data from 3 separate emergency medical service teams were collected. Two teams are staffed by paramedics only (EMT-B), while another specialized team is staffed with an emergency physician (EMT-S). 5864 out-of-hospital emergencies were performed during a 12-month period and were analyzed for this study.In 124 out of 5864 (2.1%) out-of-hospital emergencies, an ECG transmission from the out-of-hospital scene to an in-hospital cardiologist on call was performed. Rate of transmission was similar between both teams (EMT-B n = 70, 2.2% vs EMT-S n = 54, 2.0%, P = .054). After coordinating with the cardiologist on call, 11 patients (15.7%) of the EMT-B (15.7%) and 24 patients (44.4%) of the EMT-S were directly transported from the scene of emergency to a cardiac catheterization laboratory (P < .001). Overall, 80% of patients treated by EMT-S, compared to 52.5% treated by the EMT-B required subsequent hospital admission (P < .05).Transmission of ECG from the out-of-hospital emergency scene to the in-hospital cardiologist is infrequently performed. The rate of STEMI in transmitted ECG's by emergency teams staffed with an emergency physician was higher compared to emergency teams staffed with paramedics only.

Telemedicine Is Associated with Faster Diagnostic Imaging in Stroke Patients: A Cohort Study

BACKGROUND

Meeting time goals for patients with time-sensitive conditions can be challenging in rural emergency departments (EDs), and adopting policies is critical. ED-based telemedicine has been proposed to improve quality and timeliness of care in rural EDs.

INTRODUCTION

The objective of this study was to test the hypothesis that diagnostic testing in telemedicine-supplemented ED care for patients with myocardial infarction (MI) and stroke would be faster than nontelemedicine care in rural EDs.

MATERIALS AND METHODS

This observational cohort study included all ED patients with MI or stroke in 19 rural critical access hospitals served by a single real-time contract-based telemedicine provider in the upper Midwest (2007-2015). The primary outcome for the MI cohort was time-to-electrocardiogram (EKG) and for the stroke cohort was time-to-head computed tomography (CT) interpretation. To measure the relationship between telemedicine and timeliness parameters, generalized estimating equations models were used, clustering on presenting hospital.

RESULTS

Of participating ED visits, 756 were included in the MI cohort (29% used telemedicine) and 140 were included in the stroke cohort (30% used telemedicine). Time-to-EKG did not differ when telemedicine was used (1% faster, 95% confidence interval [CI] -4% to 7%), or after telemedicine was implemented (4% faster, 95% CI -3% to 10%). Head CT interpretation was faster for telemedicine cases (15% faster, 95% CI 4-26%). No differences were observed in time to reperfusion therapy.

CONCLUSIONS

Telemedicine implementation was associated with more timely head CT interpretation for rural patients with stroke, but no difference in early MI care. Future work will focus on the specific manner in which telemedicine changes ED care processes and ongoing professional education.

Achieving the earliest possible reperfusion in patients with acute coronary syndrome: a current overview

Acute coronary syndrome (ACS) remains one of the leading causes of mortality worldwide. Appropriate management of ACS will lead to a lower incidence of cardiac arrest. Percutaneous coronary intervention (PCI) is the first-line treatment for patients with ACS. PCI techniques have become established. Thus, the establishment of a system of health care in the prehospital and emergency department settings is needed to reduce mortality in patients with ACS. In this review, evidence on how to achieve earlier diagnosis, therapeutic intervention, and decision to reperfuse with a focus on the prehospital and emergency department settings is systematically summarized. The purpose of this review is to generate current, evidence-based consensus on scientific and treatment recommendations for health care providers who are the initial points of contact for patients with signs and symptoms suggestive of ACS.

Selective Localization of a Novel Dendrimer Nanoparticle in Myocardial Ischemia-Reperfusion Injury

BACKGROUND

Dendrimer nanoparticle therapies represent promising new approaches to drug delivery, particularly in diseases associated with inflammatory injury. However, their application has not been fully explored in models of acute myocardial ischemia (MI) and reperfusion injury.

METHODS

White male New Zealand rabbits underwent left thoracotomy with 30-minute temporary left anterior descending artery occlusion and MI confirmed by electrocardiography and histology (MI rabbits, n = 9), or left thoracotomy and pericardial opening for 30 minutes but no left anterior descending artery occlusion (control [C] rabbits, n = 9) rabbits. Following the 30-minute period, a dendrimer (generation 6 dendrimer conjugated to cyanine-5 fluorescent dye [G6-Cy5], 6.7 nm diameter) was administered intravenously and the chest closed in layers. Animals were sacrificed at 3 hours (3 MI, 3 C), 24 hours (3 MI, 3 C), or 48 hours (3 MI, 3 C) postsurgery.

RESULTS

As compared to controls, MI rabbits had twofold G6-Cy5 uptake in the myocardial anterior wall as compared to the same region in nonischemic control rabbits at 24 hours postsurgery (6.01 ± 0.57 μg/g versus 2.85 ± 0.85 μg/g; p = 0.04). This trend was also present at 48 hours (6.38 ± 1.53 μg/g versus 3.95 ± 0.60 μg/g, p = 0.21) and was qualitatively evident on confocal microscopy. G6-Cy5 half-life in serum was approximately 12 hours, with 22% of the injected G6-Cy5 dose remaining at 48 hours.

CONCLUSIONS

This study demonstrates for the first time that dendrimer nanodevices selectively localize in ischemic as compared to healthy myocardium. This indicates that dendrimer nanodevices are promising agents to deliver drugs specifically to the ischemic myocardium to attenuate the injury. Subsequent studies will assess the efficacy of a dendrimer-drug conjugate in ameliorating reperfusion injury following MI.

Effectiveness of a Prehospital Wireless 12-Lead Electrocardiogram and Cardiac Catheterization Laboratory Activation for ST-Elevation Myocardial Infarction

The aim of the study was to determine the prevalence of false-positive and inappropriate cardiac catheterization laboratory (CCL) activation in patients suspected with ST-elevation myocardial infarction (STEMI) diverted to a percutaneous coronary intervention (PCI) facility after paramedics wireless 12-lead electrocardiogram transmission to an emergency physician at an online medical control center. This retrospective study collected data from medical records of patients with suspected STEMI from 2006 to 2014. It included demographics, coronaropathic risk factors, cardiac biomarkers, time from the first medical contact to treatment, and final diagnosis. Primary outcome was the rate of false-positive and inappropriate CCL activation. As secondary outcomes, we compared patient characteristics between cases of appropriate and inappropriate CCL activation, and we assessed the presence of cardiac biomarkers, time from first medical contact to start of PCI, and final diagnosis. Overall, 673 patients with suspected STEMI were included in the analysis. A total of 640 patients (95%) had coronarography, of which 10% (62 of 640) did not have a culprit coronary artery (false positive). Angiography was canceled for 5% (33 of 673) of patients. The total false-positive and inappropriate CCL activation rate was 14% (95 of 673). Average time from the first medical contact to the start of PCI was 47 ± 18.1 minutes. Unwanted CCL activations were more likely to involve men aged >65 years and patients with a history of coronary artery disease. In conclusion, our system of transmitted prehospital electrocardiography and STEMI interpretation by emergency physicians at an online medical control center showed a total false-positive and inappropriate CCL activation rate of 14% over the 8-year study period.

Symptom-to-door delay among patients with ST-segment elevation myocardial infarction in Singapore

OBJECTIVES

Symptom-to-door time (S2D) is one of the important components of ischaemic time, which might affect the infarct size and outcomes of acute myocardial infarction. The aim of the present study was to identify patients' characteristics associated with delayed symptom-onset-to-arrival at EDs in ST-segment elevation myocardial infarction (STEMI) patients in Singapore.

METHODS

Retrospective data of STEMI patients presenting to the ED of all public hospitals with onsite primary percutaneous coronary intervention facilities between 2010 and 2012 were obtained from the Singapore Myocardial Infarction Registry. Based on the S2D of 120 min, characteristics of patients were compared between short S2D (≤120 min) and long S2D (>120 min). Multivariate logistic and linear regression analyses were performed.

RESULTS

Out of 3848 patients, 1682 patients had an S2D of ≤120 min, and 2166 had an S2D >120 min. In the multivariate analyses, older age, Malay ethnicity, diabetes mellitus, presenting symptoms of back and epigastric pain were independently associated with long S2D. Patients who utilised the emergency medical services, presented after office hours and with symptoms of chest pain, breathlessness, diaphoresis and past history of percutaneous transluminal coronary angioplasty/primary percutaneous coronary intervention, were independently associated with short S2D. Patients with long S2D had lower probability of receiving reperfusion treatment with delayed symptom-to-balloon and door-to-balloon time and higher probabilities of complications and mortality.

CONCLUSION

The present study shows that longer S2D was associated with older age, ethnicity, diabetes mellitus, delay in receiving early reperfusion treatment and poorer prognosis.

Reperfusion treatment delays amongst patients with painless ST segment elevation myocardial infarction

OBJECTIVE

Early reperfusion therapy in the treatment of ST segment elevation myocardial infarction (STEMI) patients can improve outcomes. Silent myocardial infarction is associated with poor prognosis, but little is known about its effect on treatment delays. We aimed to characterize STEMI patients presenting without complaints of pain to the emergency departments (EDs) in Singapore.

METHODS

Retrospective data were requested from the Singapore Myocardial Infarction Registry (SMIR), a national level registry in Singapore. Painless STEMI was defined as the absence of pain (chest, back, shoulder, jaw, and epigastric pain) during ED presentation. The primary outcome was door-to-balloon (D2B) time, defined as the earliest time a patient arrived in the ED to balloon inflation. Secondary outcomes were 1-month and 1-year mortality and occurrence of adverse events.

RESULTS

From January 2010 to December 2012, the SMIR collected 6412 cases; 10.9% of patients presented without any pain. These patients were older (median age =75 v. 58 years old), more likely to be females (39.9% v. 16.1%), Chinese (74.9% v. 62.7%), obese (median body mass index [BMI] =24.5 v. 22.1), and with history of hypertension (71.1% v. 54.6%), diabetes mellitus (48.6% v. 37.0%), and acute myocardial infarction (20.0% v. 12.3%). They had a longer median D2B (80.5 v. 63 minutes, p<0.001) and a higher occurrence of 30-day (38.4% v. 5.7%) and 1-year mortality rates (47.3% v. 8.5%).

CONCLUSION

A small proportion of STEMI patients presented without any pain to the ED. They tended to have a higher D2B and risks of mortality. Targeted effort is required to improve diagnostic and treatment efficiency in this group.

Prehospital system delay in patients with ST-segment elevation myocardial infarction in Singapore

BACKGROUND

Timely reperfusion in ST-segment elevation myocardial infarction (STEMI) improves outcomes. System delay is that between first medical contact and reperfusion therapy, comprising prehospital and hospital components. This study aimed to characterize prehospital system delay in Singapore.

METHODS

A retrospective chart review was performed for 462 consecutive STEMI patients presenting to a tertiary hospital from December 2006 to April 2008. Patients with cardiac arrest secondarily presented were excluded. For those who received emergency medical services (EMS), ambulance records were reviewed. Time intervals in the hospital were collected prospectively. The patients were divided into two equal groups of high/low prehospital system delay using visual binning technique.

RESULTS

Of 462 patients, 76 received EMS and 52 of the 76 patients were analyzed. The median system delay was 125.5 minutes and the median prehospital system delay was 33.5 minutes (interquartile range [IQR]=27.0, 42.0). Delay between call-received-by-ambulance and ambulance-dispatched was 2.48 minutes (IQR=1.47, 16.55); between ambulance-dispatch and arrival-at-patient-location was 8.07 minutes (IQR=1.30, 22.13); between arrival-at- and departure-from-patient-location was 13.12 minutes (IQR=3.12, 32.2); and between leaving-patient-location to ED-registration was 9.90 minutes (IQR=1.62, 32.92). Comparing patients with prehospital system delay of less than 35.5 minutes versus more showed that the median delay between ambulance-dispatch and arrival-at-patient-location was shorter (5.75 vs. 9.37 minutes, P<0.01). The median delay between arrival-at-patient-location and leaving-patient-location was also shorter (10.78 vs. 14.37 minutes, P<0.01).

CONCLUSION

Prehospital system delay in our patients was suboptimal. This is the first attempt at characterizing prehospital system delay in Singapore and forms the basis for improving efficiency of STEMI care.

Emergency care and health systems: consensus-based recommendations and future research priorities

The theme of the 14th annual Academic Emergency Medicine consensus conference was "Global Health and Emergency Care: A Research Agenda." The goal of the conference was to create a robust and measurable research agenda for evaluating emergency health care delivery systems. The concept of health systems includes the organizations, institutions, and resources whose primary purpose is to promote, restore, and/or maintain health. This article further conceptualizes the vertical and horizontal delivery of acute and emergency care in low-resource settings by defining specific terminology for emergency care platforms and discussing how they fit into broader health systems models. This was accomplished through discussion surrounding four principal questions touching upon the interplay between health systems and acute and emergency care. This research agenda is intended to assist countries that are in the early stages of integrating emergency services into their health systems and are looking for guidance to maximize their development and health systems planning efforts.