Only a minority of US hospitals are capable of performing and any delay in time to reperfusion (D2B) after hospital arrival is associated with a higher adjusted risk of in-hospital mortality in a continuous, nonlinear fashion.96 Strict time goals for reperfusion may not always be relevant or possible for patients who have an appropriate reason for delay, including initial uncertainty about diagnosis, the need for evaluation and treatment of other life-threatening condi- tions (eg, acute respiratory failure, cardiac arrest), delays involving informed consent, and long transport times due to geographic distance or adverse weather. To reduce hospital treatment delays, the ACC initiated the D2B Alliance in 2006 to improve door-to-device times in patients with STEMI.104 The D2B Alliance goal was for participating PCI-capable hospitals to achieve a D2B time of 90 minutes for at least 75% of nontransferred patients with STEMI. The Alliance met this goal by 2008.105 A longitudinal study of hospitals par- ticipating in the NCDR CathPCI Registry demonstrated that patients treated in hospitals that had been enrolled in the D2B Alliance for 3 months were significantly more likely to have D2B times of 90 minutes than patients treated in nonenrolled In a similar manner, the AHA launched Mission: Lifeline in 2007 to improve health system readiness and response to with a focus on the continuum of care from EMS activation to primary PCI. Patients may present directly by private transport to a PCI-capable hospital, in which case all medical care occurs in a single center responsible for opti- mizing door-to-device times. For patients who call 9-1-1, direct care begins with FMC, defined as the time at which the EMS provider arrives at the patient s side. 