The ACS programme will be ongoing however a key objective of the programme is the Optimal Reperfusion Service (ORS) protocol ensuring that STEMI patients are given the best immediate treatment possible. The ORS protocol began on 1 Oct 2012 in HSE West, on 15 Oct 2012 in HSE South; and on 14 Jan 2013 in HSE DML/DNE - thus national from 14 Jan 2013.

The designated primary PCI centre hospitals are:

• Greater Dublin - St James's Hospital (24/7), Mater Misericordiae University Hospital (24/7)
• South - Cork University Hospital (24/7), Waterford Regional Hospital (9-5, Mon-Fri)
• West - University Hospital Galway (24/7), Mid Western Regional Hospital, Limerick (24/7)

The ORS protocol is a simple guideline to ensure that as many ST elevation MI (STEMI) patients get the best treatment (generally primary percutaneous coronary intervention (PPCI)) as soon as possible. This is done by the ambulance transporting a patient directly to a designated primary PCI centre within 90 minutes of confirmation of a STEMI by 12 lead ECG. If the 90 minute timeframe cannot be achieved then the Ambulance will proceed to the nearest ED Hospital where thrombolysis would be considered.

The answer is Yes, if the patient is a STEMI (confirmed by 12 lead ECG) and a transfer within 90 minutes is possible the Ambulance is contacted and a 'Code STEMI' request made to which Ambulance will react as for an emergency. If the referring clinician thinks that the patient will not make the PPCI centre within 90 minutes then thrombolysis would be considered followed by prompt transfer to a PPCI centre.

For out of hours, the options would be dependent on time it would take to get patient to a 24/7 PPCI centre. If this will always be greater than 90 minutes then thrombolysis would be considered at the non cath lab hospital however if there is a possibility that transfer can take place within 90 minutes after diagnosis then the Ambulance is contacted and a 'Code STEMI' request made to which Ambulance will react as for an emergency.

Yes. Ambulance service is committed to treat STEMI inter-hospital transfers for PPCI or rescue PCI as emergencies (Code STEMI). They will treat reperfused, post thrombolysis transfers to PCI centre as urgent - next level down.

It is expected that there will be efficiencies in Ambulance crew contacting cardiology in a PPCI centre directly to discuss patient details and condition and the approximate arrival time to better prepare for patient arrival and treatment. This conversation can also reduce any potential inappropriate activation of the cath lab and get a patient to the most appropriate centre for treatment in the shortest time.

There have been many negotiations with the ambulance services across many of the clinical programmes, including ACS. The ambulance service are re-configuring themselves and also implementing a lower tier transport service called an Intermediate Care Vehicle (ICV). 

GPs will mostly do what they do now which is in the case of acute chest pain and symptoms of an ACS call the Ambulance service who will implement the ORS protocol if a STEMI. In cases where the GP has a 12 lead ECG and is trained and confident to interpret a STEMI, the GP will now contact the Ambulance (999/112) with a 'Code STEMI'. Note: Some GPs in the North West are involved in a GP thrombolysis scheme and this will continue for the present since the present transport times to designated PPCI centres in this area are often currently well beyond 90 minutes.