State Cardiac Reperfusion Strategy (SCRS)


To improve care for all patients in NSW with a suspected Acute Coronary Syndrome (ACS) and reduce the time from symptom onset to reperfusion for patients with ST Elevation Myocardial Infarction (STEMI).


Care is tailored to specific settings so that all patients, regardless of their geographical location or presentation pathway can benefit from early access to specialist medical advice and appropriate treatment. Timely reperfusion rapidly restores blood flow to the heart, which means patients with STEMI may have better outcomes and fewer days in hospital.


The State Cardiac Reperfusion Strategy includes a range of interconnected components including:

  • Clinical Support Model (CSM)
  • Pre-Hospital Assessment for Primary Angioplasty (PAPA)
  • Paramedic Administered Pre-Hospital Thrombolyis (PHT)
  • Nurse Administered Thrombolysis (NAT).

Each Local Health District is implementing a range of strategies, which are tailored to their local resources.


Implementation of Stage 1 of the State Cardiac Reperfusion Strategy commenced in February 2010 and targeted populations within the Sydney and Newcastle Metropolitan areas. Stage 2 of the Strategy is currently in progress.

Pre-hospital Assessment for Primary Angioplasty (PAPA)

Pre-hospital Assessment for Primary Angioplasty (PAPA) is available when patients are located close to a tertiary facility, which is capable of providing 24/7 Primary Percutaneous Coronary Intervention (PPCI).

PAPA involves assessment of the patient by paramedics and recording and transmission of a 12-lead ECG to a cardiologist for expert interpretation.

If STEMI is confirmed, the patient is immediately taken to a hospital with a cardiac catheterisation laboratory for PPCI, bypassing both small facilities that are unable to provide PPCI and the emergency department. This means that treatment is provided faster.

PAPA was established at the following ten hospitals between 2010 and 2011:

  • Concord
  • John Hunter
  • Liverpool
  • Nepean
  • Prince of Wales
  • Royal North Shore
  • Royal Prince Alfred
  • St George
  • St Vincent's
  • Westmead

In 2012, Canberra Hospital agreed to provide a PAPA service for patients in Southern NSW and Wollongong Hospital was the most recent facility to implement PAPA in 2013.

Pre-Hospital Thrombolysis

Pre-Hospital Thrombolysis (PHT) involves assessment of the patient by paramedics and recording and transmission of a 12 lead ECG to a cardiologist or ED physician. The doctor calls the paramedics, and if STEMI is confirmed, protocol directed Pre-Hospital Thrombolysis is administered on the way to hospital or at the scene, unless there are contraindications.

Improve Ambulance, ED and Cardiology communication

Clinical Support Model

The Clinical Support Model (CSM) has been established to improve the care of patients who present to small hospitals by improving the levels of expertise available to clinicians. This model involves equipping small hospitals with transmission capable ECG machines and providing access to a specialist ACS ECG Reading Service for expert interpretation of ECGs. Clinicians at the small facilities are provided with rapid advice on patient management, which results in faster treatment.

Nurse Administered Thrombolysis

The Nurse Administered Thrombolysis (NAT) model is suitable for small sites without 24/7 on-site medical staff cover, where patients self-present. A 12 lead ECG is transmitted to the ACS Reading Service and if STEMI is confirmed, accredited nurses administer protocol directed thrombolysis. A statewide formal curriculum and generic competencies for NAT are currently being developed.


  • NSW Ambulance
  • All Local Health Districts

Key Dates

Pilot Sites

Implementation Sites

Central Coast Local Health DistrictCentral Coast Local Health District


PHT was implemented in June 2014. There are no small hospitals, therefore the CSM is not required.

Far West Local Health DistrictFar West Local Health District


Broken Hill Base Hospital implemented a STEMI ECG Reading Service in December 2013 to support PHT in the Broken Hill, Balranald and Wentworth communities.


Balranald Multi Purpose Service (MPS), Menindee Health Service, Ivanhoe Health Service, White Cliffs Health Service, Tibooburra Health Service and Wilcannia MPS were equipped with transmission capability in October 2013.

Broken Hill Base Hospital provides a STEMI ECG Reading Service for the entire Far West LHD.

The Royal Flying Doctor Service (RFDS) provides an ECG Reading Service for the remote sites (Menindee, Ivanhoe, White Cliffs, Tibooburra and Wilcannia) for abnormal ECGs that do not meet STEMI criteria. Broken Hill Base Hospital provides a reading service for the remaining sites.

Hunter New England Local Health DistrictHunter New England Local Health District

The SCRS was implemented across HNELHD prior to the ACI taking the lead for implementation. John Hunter Hospital provides a STEMI ECG Reading Service for the Southern section of the LHD, while Tamworth Rural Referral Hospital provides the STEMI Reading Service for the Northern section. The CSM is in place at all small health service sites across the LHD and provides support for NAT at a number of sites.

Illawarra Shoalhaven Local Health DistrictIllawarra Shoalhaven Local Health District


In March 2013, Wollongong Hospital implemented a STEMI ECG Reading Service for the LHD to support PAPA, followed by PHT in May 2013.


NAT was implemented in Milton Ulladulla Hospital in September 2013 supported by the Wollongong Hospital STEMI ECG Reading Service. Shoalhaven Hospital provides the ECG Reading Service for abnormal ECGs that do not meet STEMI criteria.

Mid North Coast Local Health DistrictMid North Coast Local Health District


Coffs Harbour and Port Macquarie Base Hospitals implemented a STEMI ECG Reading Service in February 2013 to support PHT across the LHD.


The CSM was implemented at Macksville, Bellingen and Dorrigo Hospitals in March 2015.

Murrumbidgee Local Health DistrictMurrumbidgee Local Health District


Wagga Wagga Base Hospital implemented a comprehensive ECG Reading Service in September 2013 for 9 hospital sites (Batlow, Coolamon, Henty, Gundagai, Junee, Lake Cargelligo, Lockhart, Tumut, Tumbarumba and West Wyalong) followed by Cootamundra, Temora and Urana in December 2013. Boorowa and Harden also commenced ECG transmission to Wagga Wagga base Hospital in April 2015.

Griffith Hospital implemented an ECG Reading Service for Hay, Hillston and Lake Cargelligo Hospitals in December 2013.

Another nine hospitals will go live once the relevant transmission networks are determined. (Barham, Berrigan, Corowa, Culcairn, Finley, Holbrook, Jerilderie, Tocumwal and Young).

Northern NSW Local Health DistrictNorthern NSW Local Health District


A part-time cardiac catheterisation laboratory (CCL) is available at Lismore Hospital. If a patient presents with STEMI and the CCL is open, PAPA is provided. If the CCL is not available, PHT is provided.


PHT was implemented in March 2014.


CSM has been implemented at the 10 small hospitals in the Local Health District (Bonalbo, Urbenville, Kyogle, Nimbin, Casino, Maclean, Ballina, Byron, Mullumbimby and Murwillumbah).

Southern NSW Local Health DistrictSouthern NSW Local Health District


Canberra Hospital provides PAPA to patients from some parts of Southern NSW Local Health District (Braidwood, Cooma, Jindabyne, Queanbeyan, Yass).


An ECG reading service has been established from Crookwell to Goulburn, and Pambula to Bega.

Western NSW Local Health DistrictWestern NSW Local Health District


Implementation of PHT was completed in March 2014.


The CSM was implemented in December 2014 at the 35 small hospitals in the Local Health District (Blayney, Oberon, Rylstone, Baradine, Bourke, Brewarrina, Canowindra, Cobar, Collarenebri, Condobolin, Coolah, Coonabarabran, Coonamble, Cowra, Dunedoo, Eugowra, Forbes, Gilandra, Grenfell, Gulgargambone, Gulgong, Lightening Ridge, Molong, Mudgee, Narromine, Nyngan, Parkes, Peak Hill, Trangie, Tottenham, Trundle, Tullamore, Walgett, Warren, Wellington).


A minimum dataset has been developed to facilitate data collection at each site. All elements of the strategy are being evaluated by the ACI against measures reflecting outcomes for patients, staff and health services so that better practices can be continuously identified, shared and promoted across NSW.

Related Initiatives

Further Details

Fact sheets and protocols are available on the SCRS page of the ACI website.


Bridie Carr
Manager, Cardiac Network
02 9464 4620

Daniel Comerford
Director, Acute Care
02 9464 4602

Page Top | Added: 11 July 2013 | Last modified: 21 May 2015

Bridie Carr
Manager, Cardiac Network
02 9464 4620