A Method for Improving Arrival‐to‐electrocardiogram Time in Emergency Department Chest Pain Patients and the Effect on Door‐to‐balloon Time for ST‐segment Elevation Myocardial Infarction

Abstract

Objectives: The objectives were to determine if an emergency department (ED) could improve the adherence to a door-to-electrocardiogram (ECG) time goal of 10 minutes or less for patients who presented to an ED with chest pain and the effect of this adherence on door-to-balloon (DTB) time for ST-segment elevation myocardial infarction (STEMI) cardiac catheterization (cath) alert patients.Methods: This was a planned 1-month before-and-after interventional study design for implementing a new process for obtaining ECGs in patients presenting to the study ED with chest pain. Prior to the change, patients were registered and triaged before an ECG was obtained. The new procedure required registration clerks to identify those with chest pain and directly overhead page or call a designated ECG technician. This technician had other ED duties, but prioritized performing ECGs and delivering them to attending physicians. A full registration process occurred after the clinical staff performed their initial assessment. The primary outcome was the total percentage of patients with chest pain who received an ECG within 10 minutes of ED arrival. The secondary outcome was DTB time for patients with STEMI who were emergently cath alerted. Data were analyzed using mean differences, 95% confidence intervals (CIs), and relative risk (RR) regression to adjust for possible confounders.Results: A total of 719 patients were studied: 313 before and 405 after the intervention. The mean (±standard deviation [SD]) age was 50 (±16) years, 54% were women, 57% were African American, and 36% were white. Patients walked in 89% of the time; 11% arrived by ambulance. Thirty-nine percent were triaged as emergent and 61% as nonemergent. Patients presented during daytime 68% of the time, and 32% presented during the night. Before the intervention, 16% received an ECG at 10 minutes or less. After the intervention, 64% met the time requirement, for a mean difference of 47.3% (95% CI = 40.8% to 53.3%, p < 0.0001). Results were not affected by age, sex, race, mode of arrival, triage classification, or time of arrival. For patients with STEMI cath alerts, four were seen before and seven after the intervention. No patients before the intervention had ECG time within 10 minutes, and one of four had DTB time of <90 minutes. After the intervention, all seven patients had ECG time within 10 minutes; the three arriving during weekday hours when the cath team was on site had DTB times of <90 minutes, but the four arriving at night and on weekends when the cath team was off site had DTB times of >90 minutes. Conclusions:The overall percentage of patients with a door-to-ECG time within 10 minutes improved without increasing staffing. An ECG was performed within 10 minutes of arrival for all patients who were STEMI cath alerted, but DTB time under 90 minutes was achieved only when the cath team was on site.ACADEMIC EMERGENCY MEDICINE 2009; 16:921-927 ª

Reduced door-to-balloon times in acute ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

“…This simple approach minimized the possibility of misdiagnosis or delayed diagnosis of STEMI and shortened the doorto-ECG time. Takakuwa et al (21) employed a similar strategy to reduce the door-to-ECG and D2B time in STEMI patients and found that the door-to-ECG time was indeed reduced significantly; however, the total D2B time without other supplementary measures was not reduced. In our study, use of routine ECG examinations for chest pain patients only resulted in the reduction of the door-to-ECG time from 4 to 2 min.…”

A systematic review of factors predicting door to balloon time in ST-segment elevation myocardial infarction treated with percutaneous intervention

“…Care processes associated with shorter door to balloon times are presented in Table 4 and include: ER physician activates cath lab (including several variations) [80,[82][83][84]88,93,95,100], single call to a central page to activate cath lab [78,100], requiring that staff arrive within 20 min of page [100], ER activating cath lab while patient is en route [100], ER and cath lab receiving real time feedback [100], attending cardiologist always on site [100], passive monitoring of physician performance [92], obtaining a pre-hospital ECG (including several variations) [15,16,23,25,29,35,37,57,63,64,77,97], initial culprit vessel PCI before full diagnostic angiography [19,46] and initiation of a quality improvement initiative or critical pathway [17,79,87,[89][90][91]94,96,99]. Longer times are reported with improperly low initial triage of emergency patients with STEMI [66] and use of an intraaortic balloon pump [5].…”

The effect of failure mode and effect analysis on reducing percutaneous coronary intervention hospital door-to-balloon time and mortality in ST segment elevation myocardial infarction

“…This process resulted in delays of about 20 min before diagnosis. Some studies found that increasing the number of ED technicians or triage nursing staff members can reduce door-to-ECG time 25 26. Instead of increasing staff, we altered our process so that nurses and technician staff were trained to know that an ECG should be performed immediately (prior to analysis of vital signs, etc) if a patient arrived with chest pain, and that this was a high priority.…”

“…The ability to achieve timely reperfusion for patients with STEMI is dependent on the efficient activation of the cardiac team and execution of PCI, and on the time necessary to transport the patient and prompt contact from a non-PCI capable hospital to a hospital with catheterisation capabilities 25 26. It is recommended that the transfer time should be <60 min 6.…”