Improving door-to-needle times for patients presenting with ST-elevation myocardial infarction at a rural district general hospital

Abstract

Acute coronary syndrome is a common condition with a major global impact on healthcare resources and expenditure. International guidelines are clear in specifying that patients with acute ST-elevation myocardial infarction (STEMI) should receive urgent coronary reperfusion with either primary percutaneous coronary intervention (PCI) or thrombolysis. Although PCI is the gold standard in the treatment of STEMI, this is not always achievable in a rural hospital with no cardiac catheterization service. Consequently, local recommendations on STEMI management exist to promote timely administration of thrombolysis within 30 minutes of patient arrival. However, translating updated clinical policy into practice is a challenging and complex task that requires a multi-faceted approach with sustained engagement from local stakeholders.Whilst working at a district general hospital in New Zealand, we noted a high incidence of patients presenting with STEMI receiving thrombolytic therapy outside the recommended 30 minutes door-to-needle time. Although final treatment was often only delayed by 5-10 minutes, we were concerned by the seemingly inconsistent management of these patients, often leading to unnecessary delays in the initiation of rapid reperfusion therapy.We therefore championed a newly updated clinical guideline and promoted an early STEMI recognition and treatment algorithm in our hospital to raise awareness amongst staff and improve door-to-needle times. We introduced a number of simple low-cost interventions that included educational sessions for junior doctors and cardiac nursing staff, as well as posters and training on the use of a remote electronic ECG interpretation system to streamline out-of-hours management.Overall, we found there to a be a steady improvement in door-to-needle times at our hospital, with 74% of patients receiving appropriate care within 30 minutes, compared to 43% prior to our interventions. This also translated to better patient outcomes.This project forms part of an ongoing process to instigate quality improvements in the management of STEMI within rural institutions. Whilst we have demonstrated improved utilisation of a local STEMI guideline and streamlining of out-of-hours services, the key challenge remains to ensure that momentum of this project continues and forms a platform for sustainable clinical improvement in the long term.

Acute myocardial infarction at a district hospital in KwaZulu-Natal – Management and outcomes

“…In-service training with medical and nursing teams focused on recognition, investigation and management of STEMI and off-site ECG interpretation in a setting of clinical uncertainty. 25 Door-to-needle times improved from 43% baseline to 74% within 6 months post intervention. 25 Streptokinase causes significant delays and is used for patients at WWH.…”

“… 25 Door-to-needle times improved from 43% baseline to 74% within 6 months post intervention. 25 Streptokinase causes significant delays and is used for patients at WWH. 26 Another study concluded that Tenecteplase (TNK) takes 10.5 min less time to prepare than standard treatment ( p < 0.001) with 18% more patients ( p < 0.01) meeting target times.…”

Avaliação do Impacto da Implantação de um Sistema de Ambulância Pré-Hospitalar sobre Mortalidade por Infarto Agudo do Miocárdio em um País em Desenvolvimento

“…3 Na prática clínica, uma proporção significativa de pacientes não recebe atendimento que cumpra essas metas de tempo e a situação é ainda pior em comunidades rurais e áreas com poucos recursos. [3][4][5][6][7] Ainda faltam dados contemporâneos sobre o impacto do uso do atendimento pré-hospitalar no cenário do IAM, especialmente em países de baixa e média renda, principalmente na perspectiva mais generalizável de uma investigação de base comunitária, bem como informações sobre os resultados hospitalares de pacientes transportados por ambulância. No entanto, sabe-se que os primeiros minutos após o início do IAM são cruciais para o prognóstico e sobrevida do paciente e, considerando isso, é importante avaliar objetivamente os possíveis impactos do atendimento pré-hospitalar de emergência no manejo e nos desfechos do IAM.…”

Failed Prehospital Fibrinolysis in Patient With Percutaneous Coronary Intervention in St-Elevation Myocardial Infarction

“…Meta-analysis of randomized controlled trials maden by Vincent Roule et others [3] showed that compared with PPCI, prehospital fibrinolysis in the early period associated with better prognosis, included similar mortality rates, lower rates of cardiogenic shock, and higher rates of stroke in patients with ST-segment elevation myocardial infarction (STEMI). Despite the fact that the number of studies compared were relatively low, results supported an hypotise that prehospital FL with transfer to percutaneous coronary intervention (PCI) centers is a valid alternative to PPCI, which allows potential limitation of resources allocated to developing proximity 24/7 PCI facilities [4]. The benefit of PPCI over prehospital FL is not clear among patients managed early in the prehospital setting, but both of them are time-dependent with similar rates of mortality [3].…”