A modified cardiac triage strategy reduces door to ECG time in patients with ST elevation myocardial infarction

Abstract

Timely performing electrocardiography (ECG) is crucial for early detection of ST-elevation myocardial infarction (STEMI). For shortening door-to-ECG time, a chief complaint-based “cardiac triage” protocol comprising (1) raising alert among medical staff with bedside triage tags, and (2) immediate bedside ECG after focused history-taking was implemented at the emergency department (ED) in a single tertiary referral center. All patients diagnosed with STEMI visiting the ED between November 2017 and January 2020 were retrospectively reviewed to investigate the effectiveness of strategy before and after implantation. Analysis of a total of 117 ED patients with STEMI (pre-intervention group, n = 57; post-intervention group, n = 60) showed significant overall improvements in median door-to-ECG time from 5 to 4 min (p = 0.02), achievement rate of door-to-ECG time < 10 min from 45 to 57% (p = 0.01), median door-to-balloon time from 81 to 70 min (p < 0.01). Significant trends of increase in achievement rates for door-to-ECG and door-to-balloon times (p = 0.032 and p = 0.002, respectively) was noted after strategy implementation. The incidences of door-to-ECG time > 10 min for those with initially underestimated disease severity (from 90 to 10%, p < 0.01) and walk-in (from 29.2 to 8.8%, p = 0.04) were both reduced. In conclusion, a chief complaint-based “cardiac triage” strategy successfully improved the quality of emergency care for STEMI patients through reducing delays in diagnosis and treatment.

Fallacy of Median Door‐to‐ECG Time: Hidden Opportunities for STEMI Screening Improvement

“…This novelty translates to several limitations that should be considered when interpreting our study result. As noted in our prior work, 42 there is population attrition from those diagnosed with STEMI to those receiving PCI as treatment. We observed that 11.1% of patients with STEMI were not treated with PCI despite it being available.…”

“…The STEMI screening is further challenged, because the majority of ED patients presenting with symptoms that could be STEMI will not have a STEMI. This makes early risk stratification, driven primarily by chief complaints, 41 , 42 subject to a high false positive screening rate suggesting that symptoms alone are not sufficient for effective screening risk stratification. 40 Chest pain has been used as a parsimonious criterion, and at times accompanied with shortness of breath (SOB).…”

“…Prior work has showed that more broad consideration of chief complaints associated with ischemia is associated with improvements in timely D2E. 41 , 42 However, adding more criteria for intake staff to use to prompt ECGs can contribute to screening fatigue or inconsistency. 9 …”

The Impact of Emergency Department Arrival Time on Door-to-Balloon Time in Patients with ST-Segment Elevation Myocardial Infarction Receiving Primary Percutaneous Coronary Intervention

“…For outcome measurement, ECG time, cardiologist consultation time, cardiac catheterization laboratory (cath lab) activation time, the time the patient arrived at the cath lab, and balloon inflation time were obtained. We defined DTB time as the time from ED arrival to balloon inflation, door-to-ECG time as the time from ED arrival to completion of the first ECG, the ECG-to-consultation time as the time from completion of the first ECG to consultation with a cardiologist, the consultation-to-activation time as the time from cardiologist consultation to activation of the cath lab, the activation-to-cath lab-arrival time as the time from activation of the cath lab to the patient’s arrival in the cath lab, and the cath lab-arrival-to-balloon time as the time from the patient’s arrival in the cath lab to balloon inflation ( Figure 1 ) [ 1 , 2 , 3 , 7 , 8 , 9 , 19 ]. This study was approved by the Institutional Review Board of the Ditmanson Medical Foundation Chia-Yi Christian Hospital (CYCH-IRB 2022016).…”

Implementation of a Night Service of Helicopter Transportation to Reduce the Time to Revascularization in STEMI Patients in a Mountainous Region: Impact on Outcomes

“…With this aim, different strategies have been developed to reduce DTR time, including direct activation of the catheterization laboratory, completion of PCI team preparation within 20–30 min after the call, rapid data feedback, adoption of a team-based approach, and administrative support [ 12 ]. A recent study, for example, showed a 1 min improvement in DTR time by implementing a chief complaint-based “cardiac triage” protocol [ 13 ]. However, other strategies should be evaluated to achieve a reduction in DTR time.…”