Primary percutaneous coronary intervention (primary PCI) is the preferred immediate treatment for patients with acute ST elevation myocardial infarction. It is however, considerably more labour-intensive than the previous standard of care and requires an immediate response from consultant-led teams to deliver best outcomes. We describe the introduction of a comprehensive primary PCI service for Northern Ireland and suggest that the process by which it was designed, piloted, commissioned and benchmarked can serve as a prototype for other high-risk, time-sensitive clinical emergency services.