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Objectives: To obtain information regarding the current use of guidelines and protocols and quality assessment practices for the management of ST-segment elevation myocardial infarction in Minnesota hospitals without cardiac catheterization laboratories. Methods: Structured surveys were mailed in 2003 to emergency department medical directors or nurse managers in 111 hospitals in Minnesota that did not have cardiac catheterization laboratories. Of the 111 hospitals surveyed, 104 (94%) responded. Results: Sixty-three percent of responding hospitals have guidelines or protocols; 57% use standing orders for ST-segment elevation myocardial infarction. Thirty-three percent have neither. Of those with guidelines, protocols, or standing orders, 8% address triage and transfer criteria, 86% thrombolytics, 91% aspirin, and 71% beta-blockers. Fifty percent have quality assessment processes in place for ST-segment elevation myocardial infarction. Conclusions: Recommendations from the National Heart Attack Alert Program issued more than ten years ago and, more recently, the updated American College of Cardiology/American Heart Association Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction suggest development of emergency department and hospital-specific guidelines and protocols for ST-segment elevation myocardial infarction. Currently, only two thirds of community hospitals in Minnesota have these in place; when present, these guidelines are often incomplete and rarely address transfer criteria to hospitals with percutaneous coronary intervention capability. Quality assessment occurred in 50% of hospitals surveyed. Programs to help community hospitals develop and implement guidelines and quality improvement should be encouraged and supported.