The impact of door-to-electrocardiogram time on door-to-balloon time after achieving the guideline-recommended target rate

Abstract

BackgroundLittle is known about the components and contributing factors of door-to-balloon time after implementation of Door-to-Balloon Alliance quality-improving (QI) strategies, including the impact of door-to-ECG time on door-to-balloon time.ObjectiveWe investigated whether modification of emergency department (ED) triage processes could improve door-to-ECG and door-to-balloon times after implementation of QI strategies.MethodsThis was a retrospective before-and-after study of a prospectively collected database. From June 2014 to October 2014, interventions were implemented in our ED, including a protocol-driven ECG initiation and moving an ECG station and technician to the triage area. The primary outcome was the percentage of patients with ST-elevation myocardial infarction (STEMI) who received ECG within 10 min of arrival; the secondary outcome was the percentage of patients with door-to-balloon times of <90 min from arrival. Patients from the year pre- and post-QI initiative were defined as the control and intervention groups, respectively.ResultsEnrollment comprised 214 patients with STEMI: 109 before the intervention and 105 after the intervention. We analyzed the components of the door-to-balloon process and found the door-to-ECG process was the most critical interval of delay (20.8%). Unrecognized symptoms were the most common cause of delay in the door-to-ECG process resulting in a significant impact on the door-to-balloon time. The intervention group had a higher percentage of patients with door-to-ECG times <10 min than did the control group (93.3% vs. 79.8%, p = 0.005), with a corresponding improvement in door-to-balloon times <90 min (91.1% vs. 76.2%, p = 0.007). In subgroup analysis, the intervention benefits occurred only in non-transferred or walk-in patients. After adjustment for possible co-variates, the QI interventions remained a significant contributing factor for achieving the door-to-ECG and door-to-balloon targets.ConclusionsThe modification of ED triage processes through implementation of QI strategies are effective in achieving better door-to-ECG times and thus, achieving door-to-balloon times <90 min. In patients presenting with ambiguous symptoms, improved door-to ECG target achievement rates, through a protocol-driven and multidisciplinary approach allows for earlier identification of STEMI.

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

“…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]. Indeed, a previous study has reported a 30% increase in ECG workload after implementation of a triage ECG program [10]. By combining the strategies of cardiac triage and triage ECG, Coyne et al have shown a reduction of DTE time by 39% (i.e., from 23 to 14 minutes) and DTB by 12% (from 85 to 75 minutes).…”

“…As a DTE time over 10 minutes is an indicator of unacceptable emergency medical practice [1], we investigated the effectiveness of our interventions for reducing the DTE time by selecting the predictors previously reported to be related to DTE > 10 minutes, including the female gender [9], STEMI without chest pain [10,15], relatively non-severe initial presentations (i.e., Triage Category III, IV, V) [22], and walkin patients [8], for analysis. Among them, DTE time of STEMI patients assigned into a low (i.e., less severe) triage category was signi cantly improved after intervention.…”

“…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].…”

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

“…www.nature.com/scientificreports/ Effectiveness of interventions for improving DTE times. Our literature search identified four reported contributors to DTE delays, including STEMI without chest pain, underestimated disease severity (i.e., initially low triage levels of III-V), walk-in patient, and female gender [8][9][10]15,22 . Therefore, the four factors were used for evaluating the effectiveness of the program for improving DTE times in STEMI patients.…”

“…Rapid performance of electrocardiography (ECG) for STEMI identification is crucial to achieving coronary artery reperfusion. Some studies have shown that improving DTE time can shorten DTB time 8 – 10 . Although a previous large-scale multicenter study has demonstrated no significant reduction in 30-day in-hospital mortality rate for STEMI patients achieving the target time of DTB within 90 min, improving DTE and DTB times should still be persistently emphasized owing to the potential benefits of long-term reduction in mortality, improvement in left ventricular function, and decreasing the number of admissions for heart failure 11 .…”