Early ST elevation myocardial infarction in non-capable percutaneous coronary intervention centres: in situ fibrinolysis vs. percutaneous coronary intervention transfer.

AIMS: The preferred reperfusion strategy for early ST elevation myocardial infarction (STEMI, defined as time from symptoms onset ≤120 min) in non-capable percutaneous coronary intervention (PCI) centres remains controversial. We sought to compare mortality of in situ fibrinolysis vs. PCI transfer in a real-life consecutive cohort of early STEMI. METHODS AND RESULTS: Prospective multicentre STEMI registry (Catalonia 'Codi IAM' network) of all-comers in a non-capable PCI centre with symptom onset to first medical contact (FMC) <120 min. Two groups were identified: in situ fibrinolysis and transfer to a PCI-capable centre. Primary endpoint was 30-day mortality. We included 2470 patients, of whom 2227 (90.2%) and 243 (9.8%) comprised the transfer and fibrinolysis groups, respectively. In the fibrinolysis group, diagnostic and system delays were shorter (24 vs. 31 min, P < 0.001; 45 vs. 119 min, P < 0.001, respectively). Thirty-day mortality was 7.7 and 5.1% in fibrinolysis and transfer groups, respectively (P = 0.09). However, patients in the transfer group whose time FMC-device was achieved within 140 min were associated with significantly lower mortality (2.0% for FMC-device <99 min, and 4.6% for FMC-device 99-140 min; P < 0.01 and P = 0.03, respectively vs. fibrinolysis). In multivariable logistic regression analysis, reperfusion with fibrinolysis was an independent 30-day mortality predictive factor (odds ratio: 1.91, 95% confidence interval: 1.01-3.50; P = 0.04), together with age and Killip-Kimball class (both P < 0.001). CONCLUSIONS: In early STEMI patients assisted in non-capable PCI centres, in situ fibrinolysis had worse prognosis than patient transfer. Transfer to a PCI-capable centre seems recommended in patients with FMC-device delay <140 min.

Acute coronary syndrome and cocaine use: 8-year prevalence and inhospital outcomes.

AIMS: The use of cocaine as a recreational drug has increased in recent years. The aims of this study were to analyse the prevalence and in-hospital evolution of acute coronary syndrome (ACS) associated with cocaine consumption (ACS-ACC). METHODS AND RESULTS: Prospective analysis of ACS patients admitted to a coronary care unit from January 2001 to December 2008. During the study period, 2752 patients were admitted for ACS, and among these 479 were ≤50 years of age. Fifty-six (11.7%) patients had a medical history of cocaine use with an increase in prevalence from 6.8% in 2001 to 21.7% in 2008 (P = 0.035). Among patients younger than 30 years of age, 25% admitted to being users compared with 5.5% of those aged 45-50 years (P = 0.007). Similarly, the prevalence of positive urine tests for cocaine was four times higher in the younger patients (18.2 vs. 4.1%, P = 0.035). Acute coronary syndrome associated with cocaine consumption patients (n = 24; those who had a positive urine test for cocaine or who admitted to being users upon admission) had larger myocardial infarcts as indicated by troponin I levels (52.9 vs. 23.4 ng/mL, P < 0.001), lower the left ventricular ejection fraction (44.5 vs. 52.2%, P = 0.049), and increased in-hospital mortality (8.3 vs. 0.8%, P = 0.030). CONCLUSIONS: The association between cocaine use and ACS has increased significantly over the past few years. Young adults with ACS-ACC that require admission to the coronary care unit have greater myocardial damage and more frequent complications.

Differences in 30-day complications and 1-year mortality by sex in patients with a first STEMI managed by the Codi IAM network between 2010 and 2016.

INTRODUCTION AND OBJECTIVES: ST-segment elevation myocardial infarction (STEMI) emergency care networks aim to increase reperfusion rates and reduce ischemic times. The influence of sex on prognosis is still being debated. Our objective was to analyze prognosis according to sex after a first STEMI. METHODS: This multicenter cohort study enrolled first STEMI patients from 2010 to 2016 to determine the influence of sex after adjustment for revascularization delays, age, and comorbidities. End points were 30-day mortality, the 30-day composite of mortality, ventricular fibrillation, pulmonary edema, or cardiogenic shock, and 1-year all-cause mortality. RESULTS: From 2010 to 2016, 14 690 patients were included; 24% were women. The median [interquartile range] time from electrocardiogram to artery opening decreased throughout the study period in both sexes (119 minutes [85-160] vs 109 minutes [80-153] in 2010, 102 minutes [81-133] vs 96 minutes [74-124] in 2016, both P=.001). The rates of primary PCI within 120 minutes increased in the same period (50.4% vs 57.9% and 67.1% vs 72.1%, respectively; both P=.001). After adjustment for confounders, female sex was not associated with 30-day complications (OR, 1.06; 95%CI, 0.91-1.22). However, female 30-day survivors had a lower adjusted 1-year mortality than their male counterparts (HR,0.76; 95%CI, 0.61-0.95). CONCLUSIONS: Compared with men, women with a first STEMI had similar 30-day mortality and complication rates but significantly lower 1-year mortality after adjustment for age and severity.

[Clinical predictors of left main coronary artery disease in high-risk patients with a first episode of non-ST-segment elevation acute coronary syndrome]. / Variables clínicas predictoras de enfermedad del tronco común en pacientes de alto riesgo con un primer episodio de síndrome coronario agudo sin elevación del segmento ST.

INTRODUCTION AND OBJECTIVES: Risk stratification in non-ST-elevation acute coronary syndrome makes use of clinical variables that can identify patients at an increased risk of complications. Our objective was to identify clinical variables that predict significant stenosis (i.e., >50%) of the left main coronary artery in high-risk patients who have had a first episode of non-ST-elevation acute coronary syndrome but who do not have a history of coronary artery disease. METHODS: The study included 102 high-risk patients with no history of coronary artery disease who were admitted because of non-ST-elevation acute coronary syndrome. All underwent coronary angiography. Patients were divided into two groups: those with significant left main coronary artery stenosis (n=14) and those without (n=88). RESULTS: Univariate analysis showed that the variables significantly associated with left main coronary artery stenosis were age >65 years (57.1% vs 15.9%, P=.002), diabetes mellitus (71.4% vs 33.0%, P=.006), chronic renal failure (28.6% vs 5.7%, P=.019), left heart failure (71.4% vs 6.8%, P< .0001), cardiogenic shock (21.4% vs 1.1%, P=.008), and a low left ventricular ejection fraction at admission (49.9% [14.7%] vs 58.8% [9.9%], P=.044). In the multivariate analysis, the only significant independent predictor of left main coronary artery disease was left heart failure. CONCLUSIONS: The presence of left heart failure at initial assessment of high-risk patients with non-ST-elevation acute coronary syndrome but without a history of coronary artery disease could be a useful predictor of significant left main coronary artery disease.

Time-dependent effects of unfractionated heparin in patients with ST-elevation myocardial infarction transferred for primary angioplasty.

AIMS: Initial thrombolysis in myocardial infarction (TIMI) flow and mortality are related in ST-elevation myocardial infarction (STEMI) patients treated with primary angioplasty (PPCI). It is unclear whether early adjunctive treatment with unfractionated heparin (UFH) is beneficial for coronary patency. We investigated the effect of UFH administered before transfer versus in the catheterization laboratory (CathLab) on initial patency of the infarct related artery (IRA) in transferred STEMI patients treated with PPCI. METHODS AND RESULTS: Consecutive STEMI patients (n=1326, February 2007-December 2013) were allocated in two groups relative to UFH administration: pre-transfer group - administration by ambulance crew or physician-in-charge at the non-PPCI centre, 758 patients (57%); post-transfer group - administration in the CathLab, 568 patients (43%). The time range between symptom onset (SO) and UFH administration (SO-UFH) was assessed and the 1-year mortality prediction was analysed by logistic regression. Initial IRA TIMI 2-3 flow was 30.3% in pre-transfer group vs. 21.2% in post-transfer group (p<0.001). A time-dependent association was found between SO-UFH and initial TIMI 2-3 in pre- vs. post-transfer groups [<120 min: 33.2% vs. 18%, p<0.001; 120-240 min: 29.2% vs. 22.8%, p=0.18; >240 min: 25% vs. 28%, p=0.57]. No differences in major bleeding were found between groups. UFH administration before transfer remained an independent predictor for initial TIMI 2-3 flow (OR 1.60 CI 95% 1.22-2.11, p=0.01) and for 1-year mortality (OR 0.51 CI 95% 0.29-0.91, p=0.02). CONCLUSIONS: Early UFH administration in STEMI patients transferred for PPCI results in higher IRA initial patency in a time-dependent manner and improves clinical outcomes.

Cost-effectiveness of a European ST-segment elevation myocardial infarction network: results from the Catalan Codi Infart network.

OBJECTIVES: To evaluate the cost-effectiveness of the ST-segment elevation myocardial infarction (STEMI) network of Catalonia (Codi Infart). DESIGN: Cost-utility analysis. SETTING: The analysis was from the Catalonian Autonomous Community in Spain, with a population of about 7.5 million people. PARTICIPANTS: Patients with STEMI treated within the autonomous community of Catalonia (Spain) included in the IAM CAT II-IV and Codi Infart registries. OUTCOME MEASURES: Costs included hospitalisation, procedures and additional personnel and were obtained according to the reperfusion strategy. Clinical outcomes were defined as 30-day avoided mortality and quality-adjusted life-years (QALYs), before (N=356) and after network implementation (N=2140). RESULTS: A substitution effect and a technology effect were observed; aggregate costs increased by 2.6%. The substitution effect resulted from increased use of primary coronary angioplasty, a relatively expensive procedure and a decrease in fibrinolysis. Primary coronary angioplasty increased from 31% to 89% with the network, and fibrinolysis decreased from 37% to 3%. Rescue coronary angioplasty declined from 11% to 4%, and no reperfusion from 21% to 4%. The technological effect was related to improvements in the percutaneous coronary intervention procedure that increased efficiency, reducing the average length of the hospital stay. Mean costs per patient decreased from €8306 to €7874 for patients with primary coronary angioplasty. Clinical outcomes in patients treated with primary coronary angioplasty did not change significantly, although 30-day mortality decreased from 7.5% to 5.6%. The incremental cost-effectiveness ratio resulted in an extra cost of €4355 per life saved (30-day mortality) and €495 per QALY. Below a cost threshold of €30,000, results were sensitive to variations in costs and outcomes. CONCLUSIONS: The Catalan STEMI network (Codi Infart) is cost-efficient. Further studies are needed in geopolitical different scenarios.

[Post-anoxic encephalopathy after an episode of aborted sudden cardiac death]. / Encefalopatía postanoxémica tras un episodio de muerte súbita cardíaca recuperada.

INTRODUCTION AND OBJECTIVES: The presence of post-anoxic encephalopathy after an episode of aborted sudden cardiac death is a serious medical and social problem. PATIENTS AND METHOD: Of 193 patients admitted to the coronary unit during a 12-year period with aborted sudden cardiac death, 104 died (54%) and 89 survived the episode (46%). We compared the characteristics and 6-month prognosis between survivors according to the presence or absence of post-anoxic encephalopathy. RESULTS: Of 89 survivors, 38 patients were discharged alive with post-anoxic encephalopathy (42%) and 51 were discharged without neurological disturbances (58%). Patients with post-anoxic encephalopathy were older (65 13.6 vs. 59 12.9 years; p = 0.04). Mean time to care for cardiac arrest was 11.14.9 min in the post-anoxic encephalopathy group, versus 3.43 min (p < 0.01). The first documented rhythm was VF/VT in 57% and asystolia in 29% in the post-anoxic encephalopathy group, vs. 88% and 3% (p = 0.02). More than half (58%) of the patients in the post-anoxic encephalopathy group had coronary artery disease, vs. 49% (p = NS). Slightly more than half (52%) of the patients in the post-anoxic encephalopathy group had infectious complications, vs. 21% (p = 0.01). After 6 months of follow-up, mortality in patients discharged with post-anoxic encephalopathy was 62%, vs. 10% (p < 0.01); 21% of then showed significant functional improvement and 18% remained neurologically stable. CONCLUSIONS: Most patients admitted to a coronary unit with aborted sudden cardiac death died during hospitalization. Almost half of the survivors had post-anoxic encephalopathy at discharge; of these patients, 62% died within the following 6 months, and functional status improved only in a minority of them.

Thrombus age, clinical presentation, and reperfusion grade in myocardial infarction.

INTRODUCTION: Autopsy studies show that dynamic coronary thrombosis leads to infarction. We studied intracoronary thrombus age in ST-segment elevation myocardial infarction (STEMI) and its relationship with clinical presentation and epicardial reperfusion grade. METHODS AND RESULTS: Intracoronary thrombectomy was performed in 131 STEMI patients within 24 h after symptom onset, and material sufficient for pathological analysis was retrieved from 81 patients. Thrombus age was classified as fresh (<1day), lytic (1 to 5 days), or organized (>5days). A fresh thrombus was found in 48 patients (60%), whereas the thrombus showed lytic or organized changes in 33 patients (40%). Both thrombus and plaque material were aspirated in 40% of cases. Lytic or organized thrombi were aspirated in one third of the cases early (<12h) after symptom onset, and fresh thrombi were also aspirated in one third of STEMI of>12h evolution. In multivariable analysis, fresh thrombus was associated with both persistent ST-segment elevation (even after 12 h of onset) during percutaneous coronary intervention [odds ratio (OR) 4.23, 95% confidence interval (CI) 1.05-17.42, P=.042) and a previous history of ischemic heart disease (OR 4.54, 95% CI 1.41-14.64, P=.011). There were no associations between thrombus composition and epicardial reperfusion grade or the presence of the no-reflow phenomenon. Plaque components were found in all cases of distal embolization (5%). CONCLUSION: Intracoronary thrombi aspirated in STEMI frequently show more than one stage of maturation. Fresh thrombi predominate in patients with known ischemic heart disease or persistent ST-segment elevation. SUMMARY: In STEMI, thromboaspiration revealed thrombi at different stages of maturation, supporting a dynamic process of rupture and repair of the atherosclerotic plaque. Fresh thrombi were present more frequently within 12 h of infarction onset but also in patients with symptoms beyond 12 h. When containing plaque material, thrombi were often associated with macroscopic distal embolization during angioplasty.

Impact of frailty and functional status on outcomes in elderly patients with ST-segment elevation myocardial infarction undergoing primary angioplasty: rationale and design of the IFFANIAM study.

The IFFANIAM study (Impact of frailty and functional status in elderly patients with ST segment elevation myocardial infarction undergoing primary angioplasty) is an observational multicenter registry to assess the impact of frailty and functional status on outcomes of elderly patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary angioplasty. STEMI patients age 75 years or older undergoing primary angioplasty will be extensively studied during admission in 4 tertiary care Hospitals in Spain, assessing their baseline functional status (Barthel index, Lawton-Brody index), frailty (Fried criteria, FRAIL scale [fatigue, resistance, ambulation, illnesses, and loss of weight]), comorbidities (Charlson index), nutritional status (Mini Nutritional Assessment-Short Form), and quality of life (Seattle Angina Questionnaire). Participants will be managed according current recommendations. The primary outcome will be the description of 1-year mortality, its causes, and associated factors. Secondary outcomes will be functional capacity and quality of life. Results will help to better understand the impact of frailty and functional ability on outcomes in elderly STEMI patients undergoing primary angioplasty, thus potentially contributing to improving their clinical management. Higher life expectancy has resulted in a large segment of elderly population and an increase in myocardial infarction in these patients. This calls attention to healthcare systems to focus on promoting methods to improve the clinical management of this population.

Clinical characteristics and vital and functional prognosis of out-of-hospital cardiac arrest survivors admitted to five cardiac intensive care units.

INTRODUCTION AND OBJECTIVES: Survivors of out-of-hospital cardiac arrest constitute an increasing patient population in cardiac intensive care units. Our aim was to characterize these patients and determine their vital and functional prognosis in accordance with the latest evidence. METHODS: A multicenter, prospective register was constructed with information from patients admitted to 5 cardiac intensive care units from January 2010 through January 2012 with a diagnosis of resuscitated out-of-hospital cardiac arrest. The information included clinical status, cardiac arrest characteristics, in-hospital course, and vital and neurologic status at discharge and at 6 months. RESULTS: A total of 204 patients were included. In 64% of cases, a first shockable rhythm was identified. The time to return of spontaneous circulation was 29 (18) min. An etiologic diagnosis was made in 86% of patients; 44% were discharged with no neurologic sequelae; 40% died in the hospital. At 6 months, 79% of survivors at discharge were still alive and neurologically intact with minimal sequelae. Short resuscitation time, first recorded rhythm, pH on admission >7.1, absence of shock, and use of hypothermia were the independent variables associated with a good neurologic prognosis. CONCLUSIONS: Half the patients who recovered from out-of-hospital cardiac arrest had good neurologic prognosis at discharge, and 79% of survivors were alive and neurologically intact after 6 months of follow-up.

[Analysis of reperfusion delay in patients with acute myocardial infarction treated with primary angioplasty based on first medical contact and time of presentation]. / Análisis de los tiempos de atención en pacientes con infarto agudo de miocardio tratados con angioplastia primaria según su procedencia y según el horario de realización del procedimiento.

INTRODUCTION AND OBJECTIVES: In primary angioplasty, the interval between first medical contact (FMC) and reperfusion should be less than 120 minutes. The time to reperfusion varies depending on where FMC is established. Recent studies suggest longer times in patients presenting in off-hours. The objective is to evaluate the time intervals between the onset of symptoms and reperfusion according to where the FMC occurs and time of day of patient presentation. METHODS: Prospective observational study of acute myocardial infarction patients treated with primary angioplasty (February 2007 to May 2009). Depending on the FMC, patients were classified as belonging to the hospital group (hospital with primary angioplasty), the transfer group (hospital without primary angioplasty), or the emergency medical system (EMS) group (out-of-hospital care). For each group, the prehospital delay, diagnostic delay, delay in activation and/or transfer, and procedure delay were recorded. RESULTS: Primary angioplasty was performed in 457 patients: 155 in the hospital group, 228 in the transfer group and 72 in the EMS group. The median [interquartile range] door-to-reperfusion times were 80 [63-107], 148 [118-189] and 81 [66-98] minutes, respectively (P<.0001). The transfer group showed a greater delay in diagnosis (P<.0001) and delayed activation and/or transfer (P<.0001). The EMS group had the shortest total time due to a reduced prehospital delay (P=.001). No difference was found with regard to the time of presentation (P=.42). CONCLUSIONS: Transfer group patients were treated later and EMS group patients much earlier. There were no differences in association with the time of presentation. The identification of inappropriate delays should enable the introduction of measures to improve the efficiency of treatment.

Impacto pronóstico del intervencionismo coronario percutáneo primario en el paciente muy anciano: datos del registro Codi Infart / Prognostic impact of primary percutaneous coronary intervention in the very elderly stemi patient: insights from the codi infart registry

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Características clínicas, pronóstico vital y funcional de los pacientes supervivientes a una muerte súbita extrahospitalaria ingresados en cinco unidades de cuidados intensivos cardiológicos / Clinical characteristics and vital and functional prognosis of out-of-hospital cardiac arrest survivors admitted to five cardiac intensive care units

Introducción y objetivos. Los supervivientes a una muerte súbita extrahospitalaria constituyen un grupo de pacientes cada vez más numeroso en las unidades de cuidados intensivos cardiológicos. Nuestro objetivo es caracterizar a estos pacientes y determinar su pronóstico vital y funcional desde una perspectiva actualizada. Métodos. Registro prospectivo multicéntrico de los pacientes ingresados en cinco unidades de cuidados intensivos cardiológicos con el diagnóstico de muerte súbita extrahospitalaria recuperada entre enero de 2010 y enero de 2012. Se registraron datos clínicos, características de la parada cardiaca, curso hospitalario, así como el estado vital y la situación neurológica al alta y a los 6 meses. Resultados. Se incluyó a 204 pacientes. En un 64% de los casos se identificó un primer ritmo desfibrilable. El tiempo hasta la recuperación de la circulación espontánea fue de 29 ± 18 min. En un 86% se llegó a un diagnóstico etiológico. Un 44% de los pacientes fue dado de alta sin secuelas neurológicas, mientras que el 40% murió en la fase hospitalaria. A los 6 meses, el 79% de los supervivientes al alta permanecían vivos y neurológicamente indemnes o con mínimas secuelas. Un tiempo corto de reanimación, un primer ritmo desfibrilable, un pH al ingreso > 7,1, la ausencia de shock y la aplicación de hipotermia son las variables independientes asociadas a un buen pronóstico neurológico. Conclusiones. La mitad de los pacientes recuperados de una muerte súbita extrahospitalaria tenían buen pronóstico neurológico al alta. Un 79% de los supervivientes permanecían vivos y neurológicamente indemnes a los 6 meses de seguimiento (AU)

Introduction and objectives: Survivors of out-of-hospital cardiac arrest constitute an increasing patient population in cardiac intensive care units. Our aim was to characterize these patients and determine their vital and functional prognosis in accordance with the latest evidence. Methods: A multicenter, prospective register was constructed with information from patients admitted to 5 cardiac intensive care units from January 2010 through January 2012 with a diagnosis of resuscitated out-of-hospital cardiac arrest. The information included clinical status, cardiac arrest characteristics, in-hospital course, and vital and neurologic status at discharge and at 6 months. Results: A total of 204 patients were included. In 64% of cases, a first shockable rhythm was identified. The time to return of spontaneous circulation was 29 (18) min. An etiologic diagnosis was made in 86% of patients; 44% were discharged with no neurologic sequelae; 40% died in the hospital. At 6 months, 79% of survivors at discharge were still alive and neurologically intact with minimal sequelae. Short resuscitation time, first recorded rhythm, pH on admission >7.1, absence of shock, and use of hypothermia were the independent variables associated with a good neurologic prognosis. Conclusions: Half the patients who recovered from out-of-hospital cardiac arrest had good neurologic prognosis at discharge, and 79% of survivors were alive and neurologically intact after 6 months of follow-up (AU)

Consumo de cocaína en el síndrome coronario agudo / Cocaine use in acute coronary syndrome

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Modelo de intervención coronaria percutánea primaria en Cataluña / The primary percutaneous coronary intervention program in Catalonia

El Código Infarto de Cataluña se inició en junio de 2009 con el fin de implantar el tratamiento de reperfusión en red, basado en la intervención coronaria percutánea primaria, a los pacientes con infarto de miocardio y elevación del segmento ST, siguiendo las recomendaciones de las Guías de la Sociedad Europea de Cardiología. El protocolo, único para toda Cataluña, fue impulsado por la Sociedad Catalana de Cardiología y fue desarrollado conjuntamente con el Departamento de Salud, el CatSalut y el Servicio de Emergencias Médicas (SEM). El protocolo de actuación se basa en la sectorización de Cataluña alrededor de cinco centros con atención permanente, la participación de otros cinco centros con intervencionismo durante su horario laboral y la activa participación del SEM, que realiza el diagnóstico de infarto, decide el tipo de tratamiento en función de las isocronas, realiza el traslado del paciente directamente a las salas de hemodinámica y asegura su retorno a la unidad coronaria más próxima al domicilio del paciente. Otros aspectos importantes son la obligatoriedad de aceptar a los pacientes por parte de los hospitales, tanto en el traslado primario como en el retorno, y de realizar un registro por internet de los datos de todos los pacientes atendidos. Desde el inicio del programa, el número de intervenciones coronarias percutáneas primarias se ha duplicado, con una media de 250 al mes, y los tiempos de actuación se han reducido entre un 20 y un 40%, especialmente entre los pacientes atendidos inicialmente por el SEM (AU)

A myocardial infarction code of practice was introduced in Catalonia, Spain, in June 2009. Its aim was to establish a treatment network for reperfusion therapy in patients with ST-segment elevation acute myocardial infarction (STEMI) based on the use of primary percutaneous coronary interventions and implemented in accordance with the recommendations of European Society of Cardiology guidelines. The protocol for the code of practice, the only one used in Catalonia, was proposed by the Catalan Society of Cardiology and developed jointly with the Catalan Department of Health, the CatSalut and local Medical Emergency Services. The operating protocol was based on the division of Catalonia into five sectors arranged around centers operating on a 24-hour basis, the participation of five other centers where catheterization facilities were available during normal working hours, and the active participation of the Medical Emergency Services, who usually diagnose the myocardial infarction, decide on the type of treatment that can be given in the time available, transport the patient directly to the catheterization laboratory, and ensure that patients are subsequently transferred to the coronary care unit closest to their home. Other important factors are the hospital’s obligation to accept patients, both on first admission and subsequent transfer, and the establishment of an on-line data register of all patients treated. Since the start of the program, the number of primary percutaneous coronary interventions has doubled, with 250 procedures being performed each month on average, and operating delays have decreased by 20-40%, especially among patients who are first seen by the Medical Emergency Services (AU)