Browsing by Subject "Emergency Medical Services"

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    ItemOpen Access
    An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country.
    (PloS one, 2020-01) Zimmerman, Armand; Fox, Samara; Griffin, Randi; Nelp, Taylor; Thomaz, Erika Bárbara Abreu Fonseca; Mvungi, Mark; Mmbaga, Blandina T; Sakita, Francis; Gerardo, Charles J; Vissoci, Joao Ricardo Nickenig; Staton, Catherine A; Staton, Catherine A

    Background

    Trauma is a leading cause of death and disability worldwide. In low- and middle-income countries (LMICs), trauma patients have a higher risk of experiencing delays to care due to limited hospital resources and difficulties in reaching a health facility. Reducing delays to care is an effective method for improving trauma outcomes. However, few studies have investigated the variety of care delays experienced by trauma patients in LMICs. The objective of this study was to describe the prevalence of pre- and in-hospital delays to care, and their association with poor outcomes among trauma patients in a low-income setting.

    Methods

    We used a prospective traumatic brain injury (TBI) registry from Kilimanjaro Christian Medical Center in Moshi, Tanzania to model nine unique delays to care. Multiple regression was used to identify delays significantly associated with poor in-hospital outcomes.

    Results

    Our analysis included 3209 TBI patients. The most common delay from injury occurrence to hospital arrival was 1.1 to 4.0 hours (31.9%). Most patients were evaluated by a physician within 15.0 minutes of arrival (69.2%). Nearly all severely injured patients needed and did not receive a brain computed tomography scan (95.0%). A majority of severely injured patients needed and did not receive oxygen (80.8%). Predictors of a poor outcome included delays to lab tests, fluids, oxygen, and non-TBI surgery.

    Conclusions

    Time to care data is informative, easy to collect, and available in any setting. Our time to care data revealed significant constraints to non-personnel related hospital resources. Severely injured patients with the greatest need for care lacked access to medical imaging, oxygen, and surgery. Insights from our study and future studies will help optimize resource allocation in low-income hospitals thereby reducing delays to care and improving trauma outcomes in LMICs.
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    Analysis of the equity of emergency medical services: a cross-sectional survey in Chongqing city.
    (Int J Equity Health, 2015-12-21) Liu, Yalan; Jiang, Yi; Tang, Shenglan; Qiu, Jingfu; Zhong, Xiaoni; Wang, Yang
    BACKGROUND: Due to reform of the economic system and the even distribution of available wealth, emergency medical services (EMS) experienced greater risks in equity. This study aimed to assess the equity of EMS needs, utilisation, and distribution of related resources, and to provide evidence for policy-makers to improve such services in Chongqing city, China. METHODS: Five emergency needs variables (mortality rate of maternal, neonatal, cerebrovascular, cardiovascular, injury and poisoning) from the death surveillance, and two utilisation variables (emergency room visits and rate of utilisation) were collected from Chongqing Health Statistical Year Book 2008 to 2012. We used a concentration index (CI) to assess equality in the distribution of needs and utilisation among three areas with different per-head gross domestic product (GDP). In each area, we randomly chose two districts as sample areas and selected all the medical institutions with emergency services as subjects. We used the Gini coefficient (G) to measure equity in population and geographic distribution of facilities and human resources related EMS. RESULTS: Maternal-caused (CI: range -0.213 to -0.096) and neonatal-caused (CI: range -0.161 to -0.046)deaths declined in 2008-12, which focusing mainly on the less developed area. The maternal deaths were less equitably distributed than neonatal, and the gaps between areas gradually become more noticeable. For cerebrovascular (CI: range 0.106 to 0.455), cardiovascular (CI: range 0.101 to 0.329), injury and poisoning (CI: range 0.001 to 0.301) deaths, we documented a steady improvement of mortality; the overall equity of these mortalities was lower than those of maternal and neonatal mortalities, but distinct decreases were seen over time. The patients in developed area were more likely to use EMS (CI: range 0.296 to 0.423) than those in less developed area, and the CI increased over the 5-year period, suggesting that gaps in equity were increasing. The population distribution of facilities, physicians and nurses (G: range 0.2 to 0.3) was relatively equitable; the geographic distribution (G: range 0.4 to 0.5) showed a big gap between areas. CONCLUSIONS: In Chongqing city, equity of needs, utilization, and resources allocation of EMS is low, and the provision of such services has not met the needs of patients. To narrow the gap of equity, improvement in the capability of EMS to decrease cerebrovascular, cardiovascular, injury and poisoning cases, should be regarded as a top priority. In poor areas, allocation of facilities and human resources needs to be improved, and the economy should also be enhanced.
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    Association of MDMA/ecstasy and other substance use with self-reported sexually transmitted diseases among college-aged adults: a national study.
    (Public health, 2009-08-04) Wu, L-T; Ringwalt, CL; Patkar, AA; Hubbard, RL; Blazer, DG
    MDMA/ecstasy use among college students has increased and reportedly leads to risky sexual behaviours. However, little is known about its association with sexually transmitted diseases (STDs). To evaluate this public health concern, this study examined the association between substance use (particularly MDMA) and self-reported STDs (chlamydia, gonorrhoea, herpes and syphilis) among college students and non-students aged 18-22 years (n=20,858).A cross-sectional data analysis of a national survey.Data were drawn from the 2005-2006 National Surveys on Drug Use and Health; a nationally representative survey of non-institutionalized Americans. Self-reported STDs and substance use were assessed by the audio computer-assisted self-interviewing method. The association between MDMA use and STDs was determined while taking into account young adults' use of other substances, healthcare utilization and sociodemographic characteristics.Overall, 2.1% of college students and 2.5% of non-students reported contracting an STD in the past year. MDMA use in the past year was not associated with STDs. Among non-students, onset of MDMA use before 18 years of age increased the odds of past-year STDs. In both groups, alcohol use, marijuana use, female gender and African American race increased the odds of both past-year and lifetime STDs. Additional analyses indicated that, regardless of college-attending status, greater odds of past-year STDs were noted among users of alcohol and drugs, and users of alcohol alone, but not among users of drugs alone.Alcohol use is a robust correlate of STDs. Irrespective of college-attending status, young women and African Americans have a higher rate of STDs than young men and Whites.
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    Effect of a Universal Postpartum Nurse Home Visiting Program on Child Maltreatment and Emergency Medical Care at 5 Years of Age: A Randomized Clinical Trial.
    (JAMA network open, 2021-07) Goodman, W Benjamin; Dodge, Kenneth A; Bai, Yu; Murphy, Robert A; O'Donnell, Karen

    Importance

    The Family Connects (FC) program, a community-wide nurse home visiting program for newborns, has been shown to provide benefits for children and families through the first 2 years of life. Potential longer-term outcomes for child well-being remain unknown.

    Objective

    To determine the effect of randomization to FC on child maltreatment investigations and emergency medical care through 5 years of age.

    Design, setting, and participants

    In this randomized clinical trial, families of all 4777 resident births in Durham County, North Carolina, from July 1, 2009, to December 31, 2010, were randomly assigned to receive the FC program or treatment as usual. Impact evaluation was on an intent-to-treat basis and focused on a subsample of 549 families randomly selected from the full population and included review of hospital and Child Protective Services (CPS) administrative records. Statistical analysis was conducted from November 6, 2020, to April 25, 2021.

    Interventions

    The FC programs includes 1 to 3 nurse home visits beginning at the infant age of 3 weeks designed to identify family-specific needs, deliver education and intervention, and connect families with community resources matched to their needs. Ongoing program engagement with service professionals and an electronic resource directory facilitate effective family connections to the community.

    Main outcomes and measures

    Two primary trial outcomes were CPS-recorded child maltreatment investigations and emergency medical care use based on hospital records.

    Results

    Of the 4777 randomized families, 2327 were allocated to the intervention, and 2440 were allocated to services as usual. Among the children in the full study population, 2380 (49.8%) were female, 2397 (50.2%) were male, and 3359 (70.3%) were from racial/ethnic minority groups; of the 531 children included in the impact evaluation follow-up, 284 (53.5%) were female, 247 (46.5%) were male, and 390 (73.4%) were from racial/ethnic minority groups. Negative binomial models indicated that families assigned to FC had 39% fewer CPS investigations for suspected child maltreatment through 5 years of age (95% CI, -0.80 to 0.06; 90% CI, -0.73 to -0.01; control = 44 total investigations per 100 children and intervention = 27 total investigations per 100 children); intervention effects did not differ across subgroups. Families assigned to FC also had 33% less total child emergency medical care use (95% CI, -0.59 to -0.14; 90% CI, -0.55 to -0.18; control = 338 visits and overnight hospital stays per 100 children and intervention = 227 visits and overnight hospital stays per 100 children). Positive effects held across birth risk, child health insurance, child sex, single-parent status, and racial/ethnic groups. Effects were larger for nonminority families compared with minority families.

    Conclusions and relevance

    The findings of this randomized clinical trial suggest that, when implemented with high quality and broad reach, a brief postpartum nurse home visiting program can reduce population rates of child maltreatment and emergency medical care use in early childhood.

    Trial registration

    ClinicalTrials.gov Identifier: NCT01406184.
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    Effectiveness of Acute Care Remote Triage Systems: a Systematic Review.
    (Journal of general internal medicine, 2020-07) Boggan, Joel C; Shoup, John Paul; Whited, John D; Van Voorhees, Elizabeth; Gordon, Adelaide M; Rushton, Sharron; Lewinski, Allison A; Tabriz, Amir A; Adam, Soheir; Fulton, Jessica; Kosinski, Andrzej S; Van Noord, Megan G; Williams, John W; Goldstein, Karen M; Gierisch, Jennifer M

    Background

    Technology-based systems can facilitate remote decision-making to triage patients to the appropriate level of care. Despite technologic advances, the effects of implementation of these systems on patient and utilization outcomes are unclear. We evaluated the effects of remote triage systems on healthcare utilization, case resolution, and patient safety outcomes.

    Methods

    English-language searches of MEDLINE (via PubMed), EMBASE, and CINAHL were performed from inception until July 2018. Randomized and nonrandomized comparative studies of remote triage services that reported healthcare utilization, case resolution, and patient safety outcomes were included. Two reviewers assessed study and intervention characteristics independently for study quality, strength of evidence, and risk of bias.

    Results

    The literature search identified 5026 articles, of which eight met eligibility criteria. Five randomized, two controlled before-and-after, and one interrupted time series study assessed 3 categories of remote triage services: mode of delivery, triage professional type, and system organizational level. No study evaluated any other delivery mode other than telephone and in-person. Meta-analyses were unable to be performed because of study design and outcome heterogeneity; therefore, we narratively synthesized data. Overall, most studies did not demonstrate a decrease in primary care (PC) or emergency department (ED) utilization, with some studies showing a significant increase. Evidence suggested local, practice-based triage systems have greater case resolution and refer fewer patients to PC or ED services than regional/national systems. No study identified statistically significant differences in safety outcomes.

    Conclusion

    Our review found limited evidence that remote triage reduces the burden of PC or ED utilization. However, remote triage by telephone can produce a high rate of call resolution and appears to be safe. Further study of other remote triage modalities is needed to realize the promise of remote triage services in optimizing healthcare outcomes.

    Protocol registration

    This study was registered and followed a published protocol (PROSPERO: CRD42019112262).
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    Emergency medical services use and its association with acute ischaemic stroke evaluation and treatment in Singapore.
    (Stroke and vascular neurology, 2020-06) Xu, Hanzhang; Xian, Ying; Woon, Fung Peng; Bettger, Janet Prvu; Laskowitz, Daniel T; Ng, Yih Yng; Ong, Marcus Eng Hock; Matchar, David Bruce; De Silva, Deidre Anne

    Background

    Emergency medical services (EMS) is a critical link in the chain of stroke survival. We aimed to assess EMS use for stroke in Singapore, identify characteristics associated with EMS use and the association of EMS use with stroke evaluation and treatment.

    Methods

    The Singapore Stroke Registry combines nationwide EMS and public hospital data for stroke cases in Singapore. Multivariate regressions with the generalised estimating equations were performed to examine the association between EMS use and timely stroke evaluation and treatment.

    Results

    Of 3555 acute ischaemic patients with symptom onset within 24 hours admitted to all five public hospitals between 2015 and 2016, 68% arrived via EMS. Patients who used EMS were older, were less likely to be female, had higher stroke severity by National Institute of Health Stroke Scale and had a higher prevalence of atrial fibrillation or peripheral arterial disease. Patients transported by EMS were more likely to receive rapid evaluation (door-to-imaging time ≤25 min 34.3% vs 11.1%, OR=2.74 (95% CI 1.40 to 5.38)) and were more likely to receive intravenous tissue plasminogen activator (tPA, 22.8% vs 4.6%, OR=4.61 (95% CI 3.52 to 6.03)). Among patients treated with tPA, patients who arrived via EMS were more likely to receive timely treatment than self-transported patients (door-to-needle time ≤60 min 52.6% vs 29.4%, OR=2.58 (95% CI 1.35 to 4.92)).

    Conclusions

    EMS use is associated with timely stroke evaluation and treatment in Singapore. Seamless EMS-Hospital stroke pathways and targeted public campaigns to advocate for appropriate EMS use have the potential to improve acute stroke care.
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    Ice storm-related carbon monoxide poisonings in North Carolina: a reminder.
    (Southern medical journal, 2004-11) Ghim, Michael; Severance, Harry W
    Severe winter weather, such as ice storms, that results in loss of electrical power, is frequently mentioned as a contributing factor in acute carbon monoxide (CO) poisoning. However, in our literature review, such events are infrequently reported. This article reports on such an event in which more than 200 patients were evaluated and treated at a single facility because of the crippling effects of an ice storm leading to prolonged loss of power and subsequent catastrophes with alternative heating and cooking sources. One hundred seventy-six patients were treated and subsequently released after Emergency Department-based treatment for CO exposure, and three patients were admitted. Eighteen patients were treated with hyperbaric treatments and discharged. Three others left before treatment was completed. Three cases representing varying levels of severity at presentation leading to differing treatment algorithms are discussed to demonstrate a suggested clinical decision pathway in the treatment of unintentional CO poisoning.
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    Implementation and randomized controlled trial evaluation of universal postnatal nurse home visiting.
    (Am J Public Health, 2014-02) Dodge, KA; Goodman, WB; Murphy, RA; O’Donnell, K; Sato, J; Guptill, S
    OBJECTIVES: We evaluated whether a brief, universal, postnatal nurse home-visiting intervention can be implemented with high penetration and fidelity, prevent emergency health care services, and promote positive parenting by infant age 6 months. METHODS: Durham Connects is a manualized 4- to 7-session program to assess family needs and connect parents with community resources to improve infant health and well-being. All 4777 resident births in Durham, North Carolina, between July 1, 2009, and December 31, 2010, were randomly assigned to intervention and control conditions. A random, representative subset of 549 families received blinded interviews for impact evaluation. RESULTS: Of all families, 80% initiated participation; adherence was 84%. Hospital records indicated that Durham Connects infants had 59% fewer infant emergency medical care episodes than did control infants. Durham Connects mothers reported fewer infant emergency care episodes and more community connections, more positive parenting behaviors, participation in higher quality out-of-home child care, and lower rates of anxiety than control mothers. Blinded observers reported higher quality home environments for Durham Connects than for control families. CONCLUSIONS: A brief universal home-visiting program implemented with high penetration and fidelity can lower costly emergency medical care and improve family outcomes.
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    National Trends in Emergency Department Care Processes for Acute Myocardial Infarction in the United States, 2005 to 2015.
    (Journal of the American Heart Association, 2020-10) Pendyal, Akshay; Rothenberg, Craig; Scofi, Jean E; Krumholz, Harlan M; Safdar, Basmah; Dreyer, Rachel P; Venkatesh, Arjun K
    Background Despite investments to improve quality of emergency care for patients with acute myocardial infarction (AMI), few studies have described national, real-world trends in AMI care in the emergency department (ED). We aimed to describe trends in the epidemiology and quality of AMI care in US EDs over a recent 11-year period, from 2005 to 2015. Methods and Results We conducted an observational study of ED visits for AMI using the National Hospital Ambulatory Medical Care Survey, a nationally representative probability sample of US EDs. AMI visits were classified as ST-segment-elevation myocardial infarction (STEMI) and non-STEMI. Outcomes included annual incidence of AMI, median ED length of stay, ED disposition type, and ED administration of evidence-based medications. Annual ED visits for AMI decreased from 1 493 145 in 2005 to 581 924 in 2015. Estimated yearly incidence of ED visits for STEMI decreased from 1 402 768 to 315 813. The proportion of STEMI sent for immediate, same-hospital catheterization increased from 12% to 37%. Among patients with STEMI sent directly for catheterization, median ED length of stay decreased from 62 to 37 minutes. ED administration of antithrombotic and nonaspirin antiplatelet agents rose for STEMI (23%-31% and 10%-27%, respectively). Conclusions National, real-world trends in the epidemiology of AMI in the ED parallel those of clinical registries, with decreases in AMI incidence and STEMI proportion. ED care processes for STEMI mirror evolving guidelines that favor high-intensity antiplatelet therapy, early invasive strategies, and regionalization of care.
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    Racial/Ethnic and Sex Differences in Emergency Medical Services Transport Among Hospitalized US Stroke Patients: Analysis of the National Get With The Guidelines-Stroke Registry.
    (Journal of the American Heart Association, 2015-08-12) Mochari-Greenberger, Heidi; Xian, Ying; Hellkamp, Anne S; Schulte, Phillip J; Bhatt, Deepak L; Fonarow, Gregg C; Saver, Jeffrey L; Reeves, Mathew J; Schwamm, Lee H; Smith, Eric E
    Differences in activation of emergency medical services (EMS) may contribute to racial/ethnic and sex disparities in stroke outcomes. The purpose of this study was to determine whether EMS use varied by race/ethnicity and sex among a current, diverse national sample of hospitalized acute stroke patients.We analyzed data from 398,798 stroke patients admitted to 1613 Get With The Guidelines-Stroke participating hospitals between October 2011 and March 2014. Multivariable logistic regression was used to evaluate the associations between combinations of racial/ethnic and sex groups with EMS use, adjusting for potential confounders including demographics, medical history, and stroke symptoms. Patients were 50% female, 69% white, 19% black, 8% Hispanic, 3% Asian, and 1% other, and 86% had ischemic stroke. Overall, 59% of stroke patients were transported to the hospital by EMS. White women were most likely to use EMS (62%); Hispanic men were least likely to use EMS (52%). After adjustment for patient characteristics, Hispanic and Asian men and women had 20% to 29% lower adjusted odds of using EMS versus their white counterparts; black women were less likely than white women to use EMS (odds ratio 0.75, 95% CI 0.72 to 0.77). Patients with weakness or paresis, altered level of consciousness, and/or aphasia were significantly more likely to use EMS than patients without each symptom; the observed racial/ethnic and sex differences in EMS use remained significant after adjustment for stroke symptoms.EMS use differed by race/ethnicity and sex. These contemporary data document suboptimal use of EMS transport among US stroke patients, especially by racial/ethnic minorities and those with less recognized stroke symptoms.
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    Randomized controlled trial of universal postnatal nurse home visiting: impact on emergency care.
    (Pediatrics, 2013-11) Dodge, Kenneth A; Goodman, W Benjamin; Murphy, Robert A; O'Donnell, Karen; Sato, Jeannine
    BACKGROUND AND OBJECTIVES: Although nurse home visiting has proven efficacious with small samples, scaling up to community populations with diverse families has not yet proven effective. The Durham Connects program was developed in collaboration with community leaders as a brief, universal, postnatal nurse home visiting intervention designed to screen for risk, provide brief intervention, and connect families with more intensive evidence-based services as needed. This study tested program effectiveness in reducing infant emergency medical care between birth and age 12 months. METHODS: All 4777 resident births in Durham, North Carolina across 18 months were randomly assigned, with even birth date families to intervention and odd birth date families to control. Intervention families were offered 3 to 7 contacts between 3 and 12 weeks after birth to assess family needs and connect parents with community resources to improve infant health and well-being. Hospital records were analyzed by using an intent-to-treat design to evaluate impact among a representative subset of 549 families. RESULTS: After demographic factors (ie, birth risk, Medicaid status, ethnicity, and single parenthood) were covaried, relative to control families, families assigned to intervention had 50% less total emergency medical care use (mean [M] emergency department visits and hospital overnights) (M(intervention) = 0.78 and M(control) = 1.57; P < .001, effect size = 0.28) across the first 12 months of life. CONCLUSIONS: This brief, universal, postnatal nurse home visiting program improves population-level infant health care outcomes for the first 12 months of life. Nurse home visiting can be implemented universally at high fidelity with positive impacts on infant emergency health care that are similar to those of longer, more intensive home visiting programs. This approach offers a novel solution to the paradox of targeting by offering individually tailored intervention while achieving population-level impact.
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    Retrospective chart review and survey to identify adverse safety events in the emergency medical services care of children with out-of-hospital cardiac arrest in the USA: a study protocol.
    (BMJ open, 2020-10) Eriksson, Carl; Schoonover, Amanda; Harrod, Tabria; Meckler, Garth; Hansen, Matt; Yanez, David; Daya, Mo; Jui, Jonathan; Guise, Jeanne-Marie

    Introduction

    Efforts to improve the quality of emergency medical services (EMS) care for adults with out-of-hospital cardiac arrest (OHCA) have led to improved survival over time. Similar improvements have not been observed for children with OHCA, who may be at increased risk for preventable adverse safety events during prehospital care. The purpose of this study is to identify patient and organisational factors that are associated with adverse safety events during the EMS care of paediatric OHCA.

    Methods and analysis

    This is a large multisite EMS study in the USA consisting of chart reviews and agency surveys to measure, characterise and evaluate predictors of our primary outcome severe adverse safety events in paediatric OHCA. Using the previously validated Paediatric prehospital adverse Event Detection System tool, we will review EMS charts for 1500 children with OHCA from 2013 to 2019 to collect details of each case and identify severe adverse safety events (ASEs). Cases will be drawn from over 40 EMS agencies in at least five states in geographically diverse areas of the USA. EMS agencies providing charts will also be invited to complete an agency survey to capture organisational characteristics. We will describe the frequency and proportion of severe ASEs in paediatric OHCA across geographic regions and clinical domains, and identify patient and EMS organisational characteristics associated with severe ASEs using logistic regression.

    Ethics and dissemination

    This study has been approved by the Oregon Health & Science University Institutional Review Board (IRB Approval# 00018748). Study results will be disseminated through scientific publications and presentations, and to EMS leaders and staff through local EMS medical directors, quality and training officers and community engagement activities.
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    The left bundle-branch block puzzle in the 2013 ST-elevation myocardial infarction guideline: from falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa Criteria ready for prime time?
    (American heart journal, 2013-09) Cai, Qiangjun; Mehta, Nilay; Sgarbossa, Elena B; Pinski, Sergio L; Wagner, Galen S; Califf, Robert M; Barbagelata, Alejandro
    Prompt and accurate identification of ST-elevation myocardial infarction (STEMI) in the presence of left bundle-branch block (LBBB) remains difficult. The 2004 STEMI guideline recommended emergent reperfusion therapy to patients with suspected ischemia and new or presumably new LBBB. These recommendations have led to frequent false catheterization laboratory activation and inappropriate fibrinolytic therapy because most patients with suspected ischemia and new or presumably new LBBB do not have acute coronary artery occlusion on angiography. The new 2013 STEMI guideline makes a drastic change by removing previous recommendations. Therefore, patients with suspected ischemia and new or presumably new LBBB would no longer be treated as STEMI equivalent. The new guideline fails to recognize that some patients with suspected ischemia and LBBB do have STEMI, and denying reperfusion therapy could be fatal. The Sgarbossa electrocardiography criteria are the most validated tool to aid in the diagnosis of STEMI in the presence of LBBB. A Sgarbossa score of ≥3 has a superb specificity (98%) and positive predictive value for acute myocardial infarction and angiography-confirmed acute coronary occlusion. Thus, we propose a diagnosis and triage algorithm incorporating the Sgarbossa criteria to quickly and accurately identify, among patients presenting with chest pain and new or presumably new LBBB, those with acute coronary artery occlusion. This is a high-risk population in which reperfusion therapy would be denied by the 2013 STEMI guideline. Our algorithm will also significantly reduce false catheterization laboratory activation and inappropriate fibrinolytic therapy, the inevitable consequence of the 2004 STEMI guideline.