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

Abstract

Background ST‐segment elevation myocardial infarction (STEMI) guidelines recommend screening arriving emergency department (ED) patients for an early ECG in those with symptoms concerning for myocardial ischemia. Process measures target median door‐to‐ECG (D2E) time of 10 minutes. Methods and Results This 3‐year descriptive retrospective cohort study, including 676 ED‐diagnosed patients with STEMI from 10 geographically diverse facilities across the United States, examines an alternative approach to quantifying performance: proportion of patients meeting the goal of D2E≤10 minutes. We also identified characteristics associated with D2E>10 minutes and estimated the proportion of patients with screening ECG occurring during intake, triage, and main ED care periods. We found overall median D2E was 7 minutes (IQR:4–16; range: 0–1407 minutes; range of ED medians: 5–11 minutes). Proportion of patients with D2E>10 minutes was 37.9% (ED range: 21.5%–57.1%). Patients with D2E>10 minutes, compared to those with D2E≤10 minutes, were more likely female (32.8% versus 22.6%, P =0.005), Black (23.4% versus 12.4%, P =0.005), non‐English speaking (24.6% versus 19.5%, P =0.032), diabetic (40.2% versus 30.2%, P =0.010), and less frequently reported chest pain (63.3% versus 87.4%, P <0.001). ECGs were performed during ED intake in 62.1% of visits, ED triage in 25.3%, and main ED care in 12.6%. Conclusions Examining D2E>10 minutes can identify opportunities to improve care for more ED patients with STEMI. Our findings suggest sex, race, language, and diabetes are associated with STEMI diagnostic delays. Moving the acquisition of ECGs completed during triage to intake could achieve the D2E≤10 minutes goal for 87.4% of ED patients with STEMI. Sophisticated screening, accounting for differential risk and diversity in STEMI presentations, may further improve timely detection.

Recording the Door-To-ECG Time for Patients Presenting with Acute Chest Pain to a Cardiac Emergency Unit: A Clinical Audit and Quality Improvement Project

“…15 Other confounding factors contributing to a delay in door-to-ECG time/ STEMI diagnosis could also include sex, race, language, and diabetes as previously suggested by Maame Yaa et al in his study published in Journal of American Heart Association. 16 Apart from STEMIs, our data also identified 26(15.3%) patients which were suffering from an NSTEMI and subsequently were thrombolysed within the ER and admitted in a coronary care unit for further management. The majority of these patients 15(57.8%) had rapid 10 minute ECGs done that showed features such as T-wave inversions that were suggestive of NSTEMI and were managed well before troponin levels could come back from the lab.…”

Influence of time‐to‐diagnosis on time‐to‐percutaneous coronary intervention for emergency department ST‐elevation myocardial infarction patients: Time‐to‐electrocardiogram matters

“…Similar differences in D2E have been observed among the more inclusive group of all ED STEMI patients. 9 Prior interpretations suggested the D2E difference may have been due to the inclusion of patients who were ineligible for PCI or opted for less invasive options such as medication management or hospice. However, we found significant D2E differences in a cohort of patients who received PCI, a procedure with time‐limited benefits.…”

“…Effective STEMI treatment depends on coordination of care activities from symptom onset to treatment and requires a rapid sequence of activities and care transitions in short succession, optimally within 90 min for PCI treatment. 9 , 10 , 20 There are decades of efforts to improve screening and diagnosis for patients being transferred from referring facilities and those diagnosed in the prehospital environment by EMS. 21 , 22 However, little cross‐facility work has been performed to optimize the same care intervals for ED‐diagnosed STEMI patients.…”

“…In prior work, we identified three opportunities within the ED care process to acquire an ECG. 9 The first is during ED intake when arriving patients are registered for care. During this interaction, the patient—or those accompanying them—report the primary symptoms prompting the patient to seek ED evaluation.…”

A comparison of a precordial belt ECG and a gel-adhesive electrode in terms of ECG acquisition time and usability in emergency department patients

“…ECG recording time is important for the management of patients with acute coronary syndrome (ACS), as well as for the management of other patients in the ED, ambulance, intensive care units and critical care units [3]. The ECG recording time is also of great importance in terms of correct results, correct interpretation, and correct diagnosis for cases where urgent decisions need to be made and for patients who need intervention based on this decision [10]. Therefore, in this study, the Gel-Adhesive Electrode (GAE) and precordial Belt ECG methods used in hospital ED were compared in terms of recording time.…”