Table 1

Subsequent Modifications to Initial STEMI Protocol

2005• Community hospital physicians visited by interventional cardiologist with recommendations to:
 ∘ Perform ECG within 10 min of arrival for chest pain patients
 ∘ Communicate with PCI center physicians via dedicated STEMI hotline
 ∘ Treat and triage patients without consulting with primary physicians
 ∘ Give aspirin 325 mg chewed, metoprolol 5 mg IV × 3 when not contraindicated, heparin 70 U/kg bolus without infusion, sublingual nitroglycerin or optional topical nitropaste without routine intravenous infusion, and clopidogrel 600 mg PO
 ∘ Eliminate intravenous infusions of heparin and nitroglycerin.
2006• Nurse coordinator hired to oversee program and communicate with emergency department personnel at all referring hospitals.
• Recommendations for medications listed above were formally endorsed for all STEMI patients.
• Formal next-day feedback provided to referring hospitals, including diagnostic and treatment intervals and patient outcomes.
• Quarterly “report cards” issued to each referring hospital emergency department.
2007• PCI hospital emergency physicians directly activated the interventional team (instead of discussing it first with the interventional cardiologist on call).
• A group page was implemented for simultaneous notification of all members of the interventional team and catheterization laboratory staff of an incoming STEMI patient.

ECG = electrocardiogram; IV = intravenous; PCI = percutaneous coronary intervention; PO = by mouth; STEMI = ST-segment elevation myocardial infarction.