and setbacks Criteria for an ideal primary PCI center Granger et al. (Circulation 2007) identified the following criteria of an ideal primary PCI center. Institutional resources Primary PCI is the routine treatment for eligible STEMI patients 24 hours a day, 7 days a week Primary PCI is performed as soon as possible Institution is capable of providing supportive care to STEMI patients and handling complications Written commitment by hospital administration to support the program Identifies physician director for PCI program Creates multidisciplinary group that includes input from all relevant stakeholders, including cardiology, emergency medicine, nursing, and EMS Institution designs and implements a continuing education program For institution without on-site surgical backup, there is a written agreement with tertiary institution and EMS to provide for rapid transfer of STEMI patients when needed Physician resources Interventional cardiologists meet ACC/AHA criteria for competence Interventional cardiologists participate in, and are responsive to formal on-call schedule Program requirements Minimum of 36 primary PCI procedures and 400 total PCI procedures annually Program is described in a "manual of operations" that is compliant with ACC/AHA guidelines Mechanisms for monitoring program performance and ongoing quality improvement activities Other features of ideal system Robust data collection and feedback including door-to-balloon time, first door-to-balloon time (for transferred patients), and the proportion of eligible patients receiving some form of reperfusion therapy Earliest possible activation of the cardiac cath lab, based on prehospital ECG whenever possible, and direct referral to PCI-hospital based on field diagnosis of STEMI Standardized ED protocols for STEMI management Single phone call activation of cath lab that does not depend on cardiologist interpretation of ECG Gaps and barriers to timely access to primary PCI Granger et al. (Circulation 2007) identified the following barriers to timely access to primary PCI. Busy PCI hospitals may have to divert patients Significant delays in ED diagnosis of STEMI may occur, particularly when patient does not arrive by EMS Manpower and financial considerations may prevent smaller PCI programs from providing primary PCI for STEMI 24 hours a day Reimbursement for optimal coordination of STEMI patients needs to be realigned to reflect performance In most PCI centers, cath lab staff is off-site during off hours, requiring a mandate that staff report with 20–30 minutes of cath lab activation References External links American College of Cardiology (ACC) Door to Balloon (D2B) Initiative Q&A: Improving door-to-balloon time for acute MI - American College of Physicians Reducing