Background: Acute coronary syndrome (ACS) is the most time-sensitive acute cardiac event that requires rapid dispatching and response. The medical priority dispatch system (MPDS), one of the most extensively used types of emergency dispatch systems, is hypothesized to provide better-quality prehospital emergency treatment. However, few studies have revealed the impact of MPDS use on the process of ACS care. Objective: This study aimed to investigate whether the use of MPDS was associated with higher prehospital diagnosis accuracy and shorter prehospital delay for patients with ACS transferred by an emergency medical service (EMS), using a national database in China. Methods: This retrospective analysis was based on an integrated database of China’s MPDS and hospital registry. From January 1, 2016, to December 31, 2020, EMS-treated ACS cases were divided into before MPDS and after MPDS groups in accordance with the MPDS launch time at each EMS center. The primary outcomes included diagnosis consistency between hospital admission and discharge, and prehospital delay. Multivariable logistic regression and propensity score–matching analysis were performed to compare outcomes between the 2 groups for total ACS and subtypes. Results: A total of 9806 ACS cases (3561 before MPDS and 6245 after MPDS) treated by 43 EMS centers were included. The overall diagnosis consistency of the after MPDS group (Cohen κ=0.918, P<.001) was higher than that of the before MPDS group (Cohen κ=0.889, P<.001). After the use of the MPDS, the call-to-EMS arrival time was shortened in the matched ACS cases (20.0 vs 16.0 min, P<.001; adjusted difference: –1.67, 95% CI –2.33 to –1.02; P<.001) and in the subtype of ST-elevation myocardial infarction (adjusted difference: –3.81, 95% CI –4.63 to –2.98, P<.001), while the EMS arrival-to-door time (20.0 vs 20.0 min, P=.31) was not significantly different in all ACS cases and subtypes. Conclusions: The optimized use of MPDS in China was associated with increased diagnosis consistency and a reduced call-to-EMS arrival time among EMS-treated patients with ACS. An emergency medical dispatch system should be designed specifically to fit into different prehospital modes in the EMS system on a regional basis.

: Global spread and impact of the coronavirus disease 2019 (COVID-19) pandemic are determined to a large extent, by resistance to the pandemic and public response of all countries in the world; while a country's resistance and response are in turn determined by its political and socio economic conditions. To inform future disease prevention and control, we analyzed global data to exam the relationship between state vulnerabilities and COVID-19 incidences and deaths. : Vulnerability was measured using the Fragile States Index (FSI). FSI is created by the Fund for Peace to assess levels of fragility for individual countries. Total FSI score and scores for 12 specific indicators were used as the predictor variables. Outcome variables were national cumulative COVID-19 cases and deaths up to September 16, 2020, derived the World Health Organization. Cumulative incidence rates were computed using 2019 National population derived from the World Bank, and case fatality rates were computed as the ratio of deaths/COVID-19 cases. Countries with incomplete data were excluded, yielding a final sample of 146 countries. Multivariate regression was used to examine the association between the predictor and the outcome measures. : There were dramatic cross-country variations in both FSI and COVID-19 epidemiological measurements. FSI total scores were negatively associated with both COVID-19 cumulative incidence rates (β = -0.0135, P < 0.001) and case fatality rates (β = -0.0147, P < 0.05). Of the 12 FSI indicators, three negatively associated with COVID-19 incidences were E1(Economic Decline and Poverty), E3 (Human Flight and Brain Drain), and S2 (Refugees and Internally Displaced Persons); two positively associated were P1 (State Legitimacy) and X1 (External Intervention). With regard to association with case fatality rates, C1 (Security Apparatus) was positive, and P3 (Human Rights and Rule of Law) and X1 was negative. : With FSI measures by the Fund of Peace, overall, more fragile countries are less likely to be affected by the COVID-19 pandemic, and even if affected, death rates were lower. However, poor in state legitimacy and lack of external intervention are risk for COVID-19 infection and lack of security apparatus is risky for COVID-19 death. Implications of the study findings are discussed and additional studies are needed to examine the mechanisms underpinning these relationships.

Reducing the treatment delay by organizing delivery of care on a regional basis is a priority for improving the quality of ST-segment elevated myocardial infarction (STEMI) care. This study aimed to evaluate the impact of the combined measures on quality metrics of healthcare delivery in Suzhou. The data were collected from the National Chest Pain Center (CPC) Data Reporting Database. 4775 patients were recruited, and after propensity-score matching, 1078 pairs were finally included for analysis. We examined the changes in quality metrics of care including prehospital and in-hospital processes, and clinic outcomes. Quality improvement (QI) implementation improved most process indicators. However, these improvements did not yield decreased in-hospital mortality. The door-to-balloon and the FMC-to-device time decreased from 85.0 and 98.0 min to 78 and 88 min, respectively (p < 0.001). Cases transferred directly via EMS had a greater improvement in most of process indicators. The proportion of patients transferred directly via EMS was 10.3%, much lower than that of self-transported patients at 58.3%. Tertiary hospitals showed greater performance improvement in process indicators than secondary hospitals. The percentage of cases using EMS remained low for suburban areas. The establishment of coordinated STEMI care needs to be accompanied with solving the fragmented situation of the prehospital and hospital care, and patient delay should be addressed, especially in suburban areas and on transferred-in inpatients.

Objective To evaluate changes in admission rates for and quality of healthcare of ST-segment-elevation myocardial infarction (STEMI) during the period of the COVID-19 outbreak and postoutbreak. Methods We conducted a retrospective study among patients with STEMI in the outbreak time and the postoutbreak time. Design To examine the changes in the admission rates and in quality of healthcare, by comparison between periods of the postoutbreak and the outbreak, and between the postoutbreak and the corresponding periods. Setting Data for this analysis were included from patients discharge diagnosed with STEMI from all the hospitals of Suzhou in each month of the year until the end of July 2020. Participants 1965 STEMI admissions. Primary and secondary outcome measures The primary outcome was the number of moecondary outcomnthly STEMI admissions, and the secondary outcomes were the quality metrics of STEMI healthcare. Results There were a 53% and 38% fall in daily admissions at the phase of outbreak and postoutbreak, compared with the 2019 corresponding. There remained a gap in actual number of postoutbreak admissions at 306 and the predicted number at 497, an estimated 26 deaths due to STEMI would have been caused by not seeking healthcare. Postoutbreak period of 2020 compared with corresponding period of 2019, the percentage of cases transferred by ambulance decreased from 9.3% to 4.2% (p=0.013), the door-to-balloon median time increased from 17.5 to 34.0 min (p=0.001) and the rate of percutaneous coronary intervention (PCI) therapy declined from 71.3% to 60.1% (p=0.002). Conclusions The impact of public health restrictions may lead to unexpected out-of-hospital deaths and compromised quality of healthcare for acute cardiac events. Delay or absence in patients should be continuously considered avoiding the secondary disaster of the pandemic. System delay should be modifiable for reversing the worst clinical outcomes from the COVID-19 outbreak, by coordination measures with focus on the balance between timely PCI procedure and minimising contamination of cardiac catheterisation rooms.

Objective To evaluate changes in admission rates for and quality of care of ST-Segment-Elevation Myocardial Infarction (STEMI) during the period of the coronavirus disease 2019 (COVID-19) outbreak and post COVID-19 era. Methods We conducted a retrospective cohort study of patients with STEMI in the outbreak era (between January 23, 2020 and March 27, 2020), and the post era (between March 28, 2020, and July 31, 2020) in Suzhou Province, drawn from the China Chest Pain Center Database. Results 1965 STEMI admissions were enrolled. During the corresponding period of 2019 to the post COVID-19 era, there were a 53% and 38% fall in admissions in outbreak and the post era. There remained a gap in actual number of admissions at 306 and the predicted number that might be at 497. An estimated 26 deaths due to STEMI would have been caused by not seeking health care while no one died from COVID-19. The percentage of STEMI cases transferred by ambulance decreased from 9.3% to 4.2% (P=0.013). Door-to-balloon and the FMC-to-device median (q1, q3) time increased from 17.5 (10.0, 46.0) and 52.0 (12.0, 86.0) minutes to 34.0 (15.0, 48.0) and 63.0 (15.0, 94.0) minutes, respectively (p=0.001, p=0.005), and rate of PCI practice declined from 71.3% to 60.1% (p=0.002). Conclusions The impact of public health restrictions in the post COVID-19 era is significant, and may lead to unexpected out-of-hospital deaths and compromised quality of STEMI care. Delay or absence in presentation in STEMI patients should be continuously considered to avoid the secondary disaster of the pandemic. System delay should be modifiable for reversing the worse clinical outcomes from the COVID-19 outbreak, by coordination measures with focus on the balance between timely PCI procedure and minimizing contamination of cardiac catheterization rooms.