Interventions to reduce emergency department door-to- electrocardiogram times: A systematic review

Abstract

ObjectivesWe sought to identify emergency department interventions that lead to improvement in door-to-electrocardiogram (ECG) times for adults presenting with symptoms suggestive of acute coronary syndrome.MethodsTwo reviewers searched Medline, Embase, CINAHL, and Cochrane CENTRAL from inception to April 2018 for studies in adult emergency departments with an identifiable intervention to reduce median door-to-ECG times when compared with the institution's baseline. Quality was assessed using the Quality Improvement Minimum Quality Criteria Set critical appraisal tool. The primary outcome was the absolute median reduction in door-to-ECG times as calculated by the difference between the post-intervention time and pre-intervention time.ResultsTwo reviewers identified 809 unique articles, yielding 11 before-after quality improvement studies that met eligibility criteria (N = 15,622 patients). The majority of studies (10/11) reported bundled interventions, and most (10/11) showed statistical improvement in door-to-ECG times. The most common interventions were having a dedicated ECG machine and technician in triage (5/11); improved triage education (4/11); improved triage disposition (2/11); and data feedback mechanisms (2/11).ConclusionsThere are multiple interventions that show potential for reducing emergency department door-to-ECG times. Effective bundled interventions include having a dedicated ECG technician, triage education, and better triage disposition. These changes can help institutions attain best practice guidelines. Emergency departments must first understand their local context before adopting any single or group of interventions.

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

“…The American Heart Association (ACC/AHA) management guideline for patients presenting with symptoms of cardiac ischemia has indicated a DTB time of less than 10 min as a standard for acceptable emergency medical practice 1 . Hence, various efforts have been made to shorten the DTE time, including designation of an ECG technician and equipment for triage ECG, organization of triage education, improvement of triage disposition, and data feedback 13 . Although assigning a technician and ECG equipment to the conduction of triage ECG has been shown effective for reducing DTE time 8,17,[23][24][25] , indiscriminate ECG screening without a patient interview by an experienced emergency physician has raised the concern of increasing workload among nursing staff as well as the possibility of low cost-effectiveness 16 .…”

A modified chief complaint-based cardiac triage strategy for reducing delays in the management of patients with ST-elevation myocardial infarction

“…The American Heart Association (ACC/AHA) management guideline for patients presenting with symptoms of cardiac ischemia has indicated a DTB time of less than 10 minutes as a standard for acceptable emergency medical practice [1]. Hence, various efforts have been made to shorten the DTE time, including designation of an ECG technician and equipment for triage ECG, organization of triage education, improvement of triage disposition, and data feedback [13]. Although assigning a technician and ECG equipment to the conduction of triage ECG has been shown effective for reducing DTE time [8,17,[23][24][25], indiscriminate ECG screening without a patient interview by an experienced emergency physician has raised the concern of increasing workload among nursing staff as well as the possibility of low costeffectiveness [16].…”

“…On the other hand, only 20 to 30 percent of patients with cardiac ischemic symptoms achieved the target time of DTE within 10 minutes [8,12] so that several quality improvement programs had been proposed for shortening the DTE time. Among them, triage ECG, which is the acquisition of ECG during triage before history-taking by emergency physicians, is widely implemented in the ED setting [4,10,[13][14][15]. However, the downside of triage ECG is that, in addition to the need for setting up ECG equipment, technicians and space in the triage area, indiscriminate ECG for patients with suspected STEMI is not cost-effective and can be time-consuming so that the care for other patients could be delayed [16].…”

Strategies to measure and improve emergency department performance: a scoping review

“…Twelve reviews examined interventions relating to triage systems and processes. Triage based interventions included having a physician present [8,[16][17][18][19] also called a triage liaison physician [20], a triage team consisting of at least 2 medical personnel (nurse or physician) [21,22], dedicated triage resources (e.g., ECG machine and ECG technician [23]), triage education [23], variations of basic triage [15], triage protocols [24,25], and nurse-led triage services [26]. A description of the characteristics for each type of triage intervention is provided in Table 1.…”

“…Dedicated triage resources include a dedicated ECG technician and machine, and the creation of a dedicated ECG room with two stretchers beside triage [23] Triage Education Staff education about atypical presentations, signs and symptoms, as well as how to perform ECGs have been implemented [23] Triage Systems Variations in triage systems include prioritising patients without providing treatment, prioritising patients while providing simple treatment and formal triage systems [15] Triage Protocols Triage protocols procedures for specific symptoms and treatments, for example, nurse-requested radiograph protocol outlines the rules and procedures under which nurses can/ should request radiographs for patients at triage [24] Nurse-led Triage Nurse-led-triage involves triage by a Nurse Practitioner, Advanced Nurse Practitioner, Emergency nurse Practitioner, or ED nurse [26] Austin et al Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2020) 28:55…”