Rural versus metropolitan ST elevation infarction (STEMI) patients experience delays to care [1]. Existing NSW protocols only divert patients within 90 minutes to percutaneous coronary intervention (PCI) sites. In 2019, Western NSW Local Health District (WNSWLHD) and NSW Ambulance (NSWA) extended this range by implementing a fully centralised management system (CMS), with immediate hot transfer, for all STEMI patients to a PCI centre, covering a vast area of 250,000 km2.

Rural, versus metropolitan, Australians have higher cardiovascular mortality, driven by risk profile differences and reduced timely access to care for ST elevation myocardial infarction (STEMI) [1,2]. In 2019, a centralised management system (CMS), with routine, immediate hot transfer of STEMI patients to a PCI centre, was implemented in Western NSW Local Health District (WNSWLHD).

Acute myocarditis (AM) is uncommon but may be associated with significant acute deterioration, requiring emergency high-level tertiary level care. We therefore sought to examine the contemporary management of myocarditis presenting to a rural referral centre, comparing this to a recently proposed "risk-based approach" [1], providing a framework based on risk of deterioration, to help select those requiring transfer for tertiary level care.

Regional Australians have a higher rate of cardiovascular disease and excess mortality for AMI. This has been driven by diminished timely access to cardiac catheterisation. Orange Health Service (OHS) has developed cardiac catheter services in Western NSW LHD, an area of 276,000 km2. Starting as a diagnostic lab in 2005, the service has developed to an FFR/IVUS capable lab providing 24/7 PCI, supporting a centralised smartphone linked acute ECG reading Cardiology service and prehospital lysis for remote STEMI patients. The development of the service, percentage of patients managed in area and improvements in 30 day AMI mortality are described. Database interrogation was conducted within the OHS cardiac catheter unit database and within NSW Bureau of Health Information (BHI) 30 day AMI mortality reports. Total number of cardiac catheterisation rose (835 in 2007 to 1727 in 2019), PCI from 172 in 2007 to 576 in 2019. PCI for STEMI rose from 29 in 2009 to 208 in 2019 and by 2019 89.4% of all ACS were fully managed within the LHD. NSW BHI data showed a drop in 30 day AMI mortality from 7% in 2009- 12 to 4.8% in 2015-18 which was below the NSW average of 5.9%, with OHS being the 7th busiest catheter lab in NSW for AMI with a risk stratified mortality ratio(RSMR) of 0.91 indicated below expected deathrate for casemix. A rural cardiac catheter service providing a centralised STEMI service and 24/7 rescue PCI in a large geographical area, supported by IT and centralised transport systems, can reduce 30 day AMI mortality in a high risk population. Methodologies are applicable to other rural settings.

Background: Orange is a regional base hospital servicing a rural population of 270,775 people across 250,000km2. It offers 24/7 rescue PCI to support pre-hospital and in-hospital thrombolysis across the LHD. Additionally, PPCI is offered for patients presenting directly or by ambulance diversion to Orange within business hours and for lytic ineligible patients presenting anytime within the LHD. Methods: A retrospective audit of patients who underwent PPCI and rescue PCI at Orange Hospital from 1/1/15-31/12/15 was performed. Patients were identified using audits and medical records. Results: PPCI was performed for 22 patients: 17 presented in-hours and 5 presented out-of-hours but had a contraindication to lysis. The median door-to-balloon (DTB) time was 52min (see table). DTB times were shorter for patients who had their diagnostic ECG performed by paramedics using the LIFENET system compared to by ED (median DTB time 35min versus 74min). Rescue PCI was required in 32 of the 104 patients who were thrombolysed in 2015 (31%). The majority (68%) of rescue PCI cases were performed outside business hours (0800-1700 weekdays). Mean transport time to Orange hospital was 75+/-48min and mean transport distance was 131km. Median DTB time was 70min (see table).Tabled 1DTB time0-30min30-60min60-90min>90minPPCI (%)11442817Rescue PCI (%)19192537 Open table in a new tab Conclusion: Orange Hospital has demonstrated the feasibility of a 24/7 primary and rescue PCI service operating within a rural setting. Better systems of transport and ambulance diversion to the PPCI centre will expand the benefits of this service.

Background: Rural STEMI patients have lower rates of reperfusion and higher mortality compared to their metropolitan counterparts, in part due to the large distances and resource limitations of rural NSW. We aimed to review the contribution of patient delays in accessing timely reperfusion. Methods: A retrospective audit of STEMI patients within Western NSW LHD in 2015 was undertaken. Comparisons were made with NSW ambulance data on metropolitan STEMI patients from a single month in 2012. Results: 150 patients were diagnosed with STEMI in 2015. Of these, 49% called an ambulance and 51% presented directly to ED. For patients calling an ambulance, the median symptom-onset-to-call time was 34 min, compared to 66 min for metropolitan patients. Symptom onset to first clinical contact (FCC) was significantly longer for rural patients presenting direct to ED (median 110min) compared to those presenting via ambulance (median 72min)(p=0.037). Mean FCC time to lysis for rural ambulance was 44+/-26 min versus 60+/-33 min for ED (p=0.02). FCC was outside the thrombolysis window (12hrs) in 9% of rural patients, compared to 4% in metro patients.Tabled 1Table: Symptom onset to FCC according to mode of presentation and locationSymptom onset to FCC0-30min30-60min60-90min>90minMetro Ambulance(%)25161346Rural Ambulance(%)31171735Rural ED(%)2113956 Open table in a new tab Conclusion: The majority of rural STEMI patients do not call an ambulance, delaying care and preventing access to pre-hospital thrombolysis. Strategies to reduce these delays are vital to address disparities in clinical outcomes for rural patients.

Background: Rural compared to metropolitan STEMI patients have a higher mortality. Western NSW LHD implemented the State-wide Cardiac Reperfusion Strategy for pre-hospital thrombolysis (PHT) in 2014. Cardiologists confirm ECGs meet STEMI-criteria and paramedics then administer thrombolysis. LIFENET ECG transmission is also available within all non-base hospitals throughout the LHD. We hypothesised that PHT and use of LIFENET would achieve shorter first-contact-to-needle (FCTN) times than in-hospital thrombolysis (IHT). Methods: We retrospectively analysed data on all STEMI patients who underwent thrombolysis within the Western NSW LHD in 2015. Results: 104 patients were thrombolysed for STEMI, with 65 successfully reperfusing. First medical contact was with paramedics in 46% of cases and with ED in 54%. Paramedics administered thrombolysis in 28% of cases and ED in 72%. Overall, mean FCTN time was 55+/-32 min (Table 1). The mean FCTN time for PHT was significantly less than for IHT (44+/-26 min versus 60+/-33 min; p=0.02). There was a non-significant trend towards shorter FCTN times for patients presenting to small rural hospitals whose diagnostic ECG was sent via LIFENET involving early cardiologist input as compared to routine care (55+/-30 min versus 58+/-38; p>0.05).Tabled 1FCTN time0-30min30-60min60-90min>90minPHT(%)275977IHT(%)19411921 Open table in a new tab Conclusion: PHT has achieved shorter FCTN times than IHT within the LHD. Expansion of the LIFENET system with early cardiologist input has scope to further improve FCTN and reduce mortality for rural STEMI patients.