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    ABSTRACT: Guidelines for patients with ST-segment elevation myocardial infarction (STEMI) recommend timely reperfusion with primary percutaneous coronary intervention (pPCI) or fibrinolysis. Among patients with STEMI who require interhospital transfer, it is unclear how reperfusion strategy selection and outcomes vary with interhospital drive times. To assess the association of estimated interhospital drive times with reperfusion strategy selection among transferred patients with STEMI in the United States. We identified 22 481 patients eligible for pPCI or fibrinolysis who were transferred from 1771 STEMI referring centers to 366 STEMI receiving centers in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines database between July 1, 2008, and March 31, 2012. In-hospital mortality and major bleeding. The median estimated interhospital drive time was 57 minutes (interquartile range [IQR], 36-88 minutes). When the estimated drive time exceeded 30 minutes, only 42.6% of transfer patients treated with pPCI achieved the first door-to-balloon time within 120 minutes. Only 52.7% of eligible patients with a drive time exceeding 60 minutes received fibrinolysis. Among 15 437 patients with estimated drive times of 30 to 120 minutes who were eligible for fibrinolysis or pPCI, 5296 (34.3%) received pretransfer fibrinolysis, with a median door-to-needle time of 34 minutes (IQR, 23-53 minutes). After fibrinolysis, the median time to transfer to the STEMI receiving center was 49 minutes (IQR, 34-69 minutes), and 97.1% underwent follow-up angiography. Patients treated with fibrinolysis vs pPCI had no significant mortality difference (3.7% vs 3.9%; adjusted odds ratio, 1.13; 95% CI, 0.94-1.36) but had higher bleeding risk (10.7% vs 9.5%; adjusted odds ratio, 1.17; 95% CI, 1.02-1.33). In the United States, neither fibrinolysis nor pPCI is being optimally used to achieve guideline-recommended reperfusion targets. For patients who are unlikely to receive timely pPCI, pretransfer fibrinolysis, followed by early transfer for angiography, may be a reperfusion option when potential benefits of timely reperfusion outweigh bleeding risk.
    No preview · Article · Dec 2014 · JAMA Internal Medicine
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    ABSTRACT: Effective treatment of acute coronary syndrome (ACS) patients depends on the transportation time to a hospital. But selection of an optimal route and target hospital for an ambulance within a large city is a complex problem. It requires taking into account the dynamical nature of an urban environment. Such dynamic factors as traffic flow, changing road graph, population mobility, and hospital capabilities are sources of uncertainty in decision making on hospitalization, and eventually they influence the functioning quality of emergency medical services (EMS) in a city. This work is devoted to the analysis of this problem for the city of Saint-Petersburg (Russia) with the use of statistical data, public geographic information services (OpenStreetMap), and real-time data on traffic flow (Yandex.Maps). It is shown that dynamic traffic conditions influence selection of a hospital and have to be considered within the task of ambulance routing. The results may be applied in order to design a more efficient EMS decision support system for ambulance personnel and dispatchers.
    Full-text · Article · Dec 2015 · Procedia Computer Science