Guideline door-to-balloon-times were more often achieved when trained paramedics independently triaged and transported patients directly to a designated primary PCI center than when patients were referred from emergency departments.

Although risk of repeat access to prehospital/ED care for patients with hypoglycemia exists, it was less common among patients taking insulin and was not predicted by an initial refusal of transport.

A STEMI system allowing EMS to transport patients directly to a primary PCI center was associated with a significant reduction in mortality. Our results support the concept of STEMI systems that include pre-hospital referral by EMS.