Using ECG-To-Activation Time to Assess Emergency Physicians’ Diagnostic Time for Acute Coronary Occlusion

McLaren, Jesse T.T.; Kapoor, Monika; Yi, Soojin L.; Chartier, Lucas B.

doi:10.1016/j.jemermed.2020.09.028

Cited by 10 publications

(8 citation statements)

References 53 publications

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“…But there is a surprising lack of complementary quality benchmark for emergency physicians, perhaps because of simplified STEMI criteria. ECG-to-Activation time reflects the diagnostic time of emergency physicians, is independent of cath lab capabilities, and can be compared across different settings; this metric can help identify preventable reperfusion delays and promote new advances in ECG interpretation [ 12 ]. In our QI project, including a grand rounds presentation based on the article by Miranda et al, followed by weekly ECG audit and feedback to all physicians on signs of OMI, ECG-to-Activation time was reduced by 20 min [ 13 ].…”

Section: Omi Paradigm and Qimentioning

confidence: 99%

From STEMI to occlusion MI: paradigm shift and ED quality improvement

et al. 2021

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A generation ago the ST-elevation myocardial infarction (STEMI) paradigm led to quality improvement (QI) in the emergency department (ED). Now, insights from angiography and advances in electrocardiogram (ECG) interpretation have led to the new paradigm of occlusion myocardial infarction (OMI), creating the possibility of further QI. This article reviews the current STEMI paradigm, the emergence of the OMI paradigm, and the use of QI to continuously improve care for acute myocardial infarction (AMI) patients in the ED.

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Section: Omi Paradigm and Qimentioning

confidence: 99%

From STEMI to occlusion MI: paradigm shift and ED quality improvement

et al. 2021

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“…Delayed or misdiagnosis of STEMI ECG significantly contributed to delayed PPCI. A recent study reported that the median EtoCCLA time requires 8 min in ED physicians, even with typical STEMI presentation on ECGs [16]. Importantly, the ECG presentations of STEMI-equivalent or subtle occlusion greatly prolonged the EtoCCLA time.…”

Section: Discussionmentioning

confidence: 99%

“…In achieving a DtoB time ≤ 90 min, the rate-determining step was DtoCCLA time, composed of DtoE and EtoCCLA time [16,26]. Although a DtoE time ≤ 10 min, as recommended in the majority of national guidelines, was notably achieved in our clinical practice, the critical role of EtoCCLA time is rarely addressed.…”

Section: Discussionmentioning

confidence: 99%

“…Through these strategies, the DtoB time was reduced from 96 to 71 min with a corresponding increase in the rate of achieving DtoB time within 90 min from 47% to 80% in Taiwan [14,15]. Importantly, reducing the time between obtaining an ECG and CCLA (EtoCCLA), which depends on a prompt diagnosis of STEMI, appears to be a key factor in shortening DtoB time [6,16]. The emergency department is a challenging environment where medical errors often occur due to intense time pressures, heavy workloads, and harried staff during busy working hours [17][18][19][20].…”

Section: Introductionmentioning

confidence: 99%

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An Artificial Intelligence-Based Alarm Strategy Facilitates Management of Acute Myocardial Infarction

Liu

Lin

Tsai

et al. 2021

JPM

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(1) Background: While an artificial intelligence (AI)-based, cardiologist-level, deep-learning model for detecting acute myocardial infarction (AMI), based on a 12-lead electrocardiogram (ECG), has been established to have extraordinary capabilities, its real-world performance and clinical applications are currently unknown. (2) Methods and Results: To set up an artificial intelligence-based alarm strategy (AI-S) for detecting AMI, we assembled a strategy development cohort including 25,002 visits from August 2019 to April 2020 and a prospective validation cohort including 14,296 visits from May to August 2020 at an emergency department. The components of AI-S consisted of chest pain symptoms, a 12-lead ECG, and high-sensitivity troponin I. The primary endpoint was to assess the performance of AI-S in the prospective validation cohort by evaluating F-measure, precision, and recall. The secondary endpoint was to evaluate the impact on door-to-balloon (DtoB) time before and after AI-S implementation in STEMI patients treated with primary percutaneous coronary intervention (PPCI). Patients with STEMI were alerted precisely by AI-S (F-measure = 0.932, precision of 93.2%, recall of 93.2%). Strikingly, in comparison with pre-AI-S (N = 57) and post-AI-S (N = 32) implantation in STEMI protocol, the median ECG-to-cardiac catheterization laboratory activation (EtoCCLA) time was significantly reduced from 6.0 (IQR, 5.0–8.0 min) to 4.0 min (IQR, 3.0–5.0 min) (p < 0.01). The median DtoB time was shortened from 69 (IQR, 61.0–82.0 min) to 61 min (IQR, 56.8–73.2 min) (p = 0.037). (3) Conclusions: AI-S offers front-line physicians a timely and reliable diagnostic decision-support system, thereby significantly reducing EtoCCLA and DtoB time, and facilitating the PPCI process. Nevertheless, large-scale, multi-institute, prospective, or randomized control studies are necessary to further confirm its real-world performance.

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“…DTE time has been widely studied and DTE time ≤ 10 min is considered a key quality metric for triage nurses [ 39 ]. We previously demonstrated that the ETA time is another important quality metric, specific to emergency physicians [ 40 ], and that it can help guide quality improvement initiatives to reduce diagnostic time for acute coronary occlusion [ 41 ]. Together, DTE and ETA times form the Door-to-Activation (DTA) time, which is a key driver of DTB time: achieving a DTA time of ≤20 min has been associated with a DTB time of ≤90 min, a widely accepted measure of STEMI quality [ 42 ].…”

Section: Discussionmentioning

confidence: 99%

Flattening the other curve: Reducing emergency department STEMI delays during the COVID-19 pandemic

McLaren¹,

Taher²,

Chartier³

2021

The American Journal of Emergency Medicine

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Background The COVID-19 pandemic has been associated with ST-Elevation Myocardial Infarction (STEMI) reperfusion delays despite reduced emergency department (ED) volumes. However, little is known about ED contributions to these delays. We sought to measure STEMI delays and ED quality benchmarks over the course of the first two waves of the pandemic. Study This study was a multi-centre, retrospective chart review from two urban, academic medical centres. We obtained ED volumes, COVID-19 tests and COVID-19 cases from the hospital databases and ED Code STEMIs with culprit lesions from the cath lab. We measured door-to-ECG (DTE) time and ECG-to-Activation (ETA) time during the phases of the pandemic in our jurisdiction: pre-first wave (Jan-Mar 2020), first wave (Apr-June 2020), post-first wave (July-Nov 2020), and second wave (Dec 2020 to Feb 2021). We calculated median DTE and ETA times and compared them to the 2019 baseline using Wilcox rank-sum test. We calculated the percentages of DTE ≤10 min and of ETA ≤10 min and compared them to baseline using chi-square test. We also utilized Statistical Process Control (SPC) Xbar-R charts to assess for special cause variation. Results COVID-19 cases began during the pre-wave phase, but there was no change in ED volumes or STEMI quality metrics. During the first wave ED volumes fell by 40%, DTE tripled (10.0 to 29.5 min, p = 0.016), ETA doubled (8.5 to 17.0 min, p = 0.04), and percentages for both DTE ≤10 min and ETA ≤10 min fell by three-quarters (each from more than 50%, to both 12.5%, both p < 0.05). After the first wave all STEMI quality benchmarks returned to baseline and did not significantly change during the second wave. A brief period of special cause variation was noted for DTE during the first wave. Conclusions Both DTE and ETA metrics worsened during the first wave of the pandemic, revealing how it negatively impacted the triage and diagnosis of STEMI patients. But these normalized after the first wave and were unaffected by the second wave, indicating that nurses and physicians adapted to the pandemic to maintain STEMI quality of care. DTE and ETA metrics can help EDs identify delays to reperfusion during the pandemic and beyond.

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Using ECG-To-Activation Time to Assess Emergency Physicians’ Diagnostic Time for Acute Coronary Occlusion

Cited by 10 publications

References 53 publications

From STEMI to occlusion MI: paradigm shift and ED quality improvement

From STEMI to occlusion MI: paradigm shift and ED quality improvement

An Artificial Intelligence-Based Alarm Strategy Facilitates Management of Acute Myocardial Infarction

Flattening the other curve: Reducing emergency department STEMI delays during the COVID-19 pandemic

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