Emergency department thrombolysis improves door to needle times

Abstract

Objective: To identify the effect on door to needle (DTN) time of moving the site of thrombolysis delivery from the coronary care unit (CCU) to the emergency department (ED). To ascertain if moving the site of thrombolysis enables appropriate use of thrombolysis. Design: Prospective cohort study. Setting: CCU and ED of a 450 bed Scottish district general hospital without on-site primary angioplasty. Participants: Primary site for thrombolysis of patients presenting to the hospital with ST elevation MI (STEMI) moved from CCU to ED on 1 April 2000. Study patients who had a confirmed STEMI and/or received thrombolytic therapy before this date were defined as the pre-change group; those who were diagnosed as STEMI and/or received thrombolytic therapy after this date were defined as the post-change group. Statistical analysis: Mann-Whitney test was used to compare medians and x 2 test for categorical data. Results: 1349 patients were discharged from CCU with a diagnosis of STEMI or received thrombolysis in the ED or CCU between April 1998 and April 2002. There were 632 patients in the pre-change group and 654 patients in the post-change group. Sixty three patients were excluded. Median DTN time for the prechange group (321 thrombolysed patients) was 64 minutes and median DTN time for the post-change group (324 thrombolysed patients) was 35 minutes, a median difference of 25 minutes (95% CI for difference 20 to 29 minutes, p,0.0001, Mann-Whitney U test). A total of 37 patients were thrombolysed but did not have a final diagnosis of STEMI. Conclusion: A significant reduction in DTN times accompanied this change in practice in this hospital.

A Review of Interventions and System Changes to Improve Time to Reperfusion for ST-Segment Elevation Myocardial Infarction

“…37,38 Three studies also included an educational component to the intervention. 32,37,41 Relative decreases in door-to-needle times for moving thrombolytic therapy to the emergency department ranged from 45 to 72%, with intervention group times ranging from 20 to 42.5 minutes.…”

“…32,[37][38][39][40][41][42][43] Two studies were conducted at hospitals that continued to admit some patients to the cardiac care unit to receive thrombolytics, thus comparisons were both pre/post intervention analysis and between delivery time in the emergency department and the cardiac care unit. 37,38 Three studies also included an educational component to the intervention.…”

“…27,28 Less than half of the studies (47%) had a sample size larger than 100 patients. 27,[29][30][31][32][33] The objective of this review is to describe and categorize interventions to reduce door-to-reperfusion times. While metaanalysis was feasible for several intervention categories, we felt that generating pooled estimates was beyond the scope of this review.…”

The effect of health care provider consultation on acute coronary syndrome care-seeking delay

“…A timeconsuming behavioral response is consultation with an HCP, yet we know little about how HCPs come to their consistently time-consuming decisions. If it is consistently shown that calling an HCP impedes the ACS care-seeking process, 6,[22][23][24][25][26][27][28][29][30][31][32][33][34][35] and if we can reduce the "Door-to-Needle" time in the treatment of ACS in the ED, 64 there is an even more compelling need to study the decision-making processes used by HCPs, primarily physicians and their office personnel, when called by individuals reporting ACS symptoms. On the basis of the present study and prior research, 6,22-35 and until we develop an ACS management protocol based on the incidence of calls to HCP offices, patients with ACS should be advised to avoid calling an HCP and to go directly to the ED to ensure rapid access to highly time-dependent reperfusion therapies.…”

Does initiation of an ambulance pre-alert call reduce the door to needle time in acute myocardial infarct?

“…[1][2] Other work has shown that paramedic electrocardiogram (ECG) interpretation and fast tracking of patients with myocardial infarction to a coronary care unit (CCU) reduces door to needle (DTN) times, [3][4][5] as does thrombolysis in the emergency department. 6 Currently our institution has a target of 30 minutes for DTN 7 in 75% of cases and that an ECG should be carried out within 10 minutes of arrival.…”