Improving Door-to-balloon Time by Decreasing Door-to-ECG time for Walk-in STEMI Patients

Introduction: The American Heart Association/American College of Cardiology guidelines recommend rapid door-to-electrocardiography (ECG) times for patients with ST-segment elevation myocardial infarction (STEMI). Previous quality improvement research at our institution revealed that we were not meeting this benchmark for walk-in STEMI patients. The objective is to investigate whether simple, directed changes in the emergency department (ED) triage process for potential cardiac patients could decrease door-to-ECG times and secondarily door-to-balloon times. Methods: We conducted an interventional study at a large, urban, public teaching hospital from April 2010 to June 2012. All patients who walked into the ED with a confirmed STEMI were enrolled in the study. The primary intervention involved creating a chief complaint-based cardiac triage designation that streamlined the evaluation of potential cardiac patients. A secondary intervention involved moving our ECG technician and ECG station to our initial triage area. The primary outcome measure was door-to-ECG time and the secondary outcome measure was door-to-balloon time. Results: We enrolled 91 walk-in STEMI patients prior to the intervention period and 141 patients after the invention. We observed statistically significant reductions in door-to-ECG time (43 +/- 93 to 30 +/- 72 minutes, median 23 to 14 minutes p<0.01), ECG-to-activation time (87 +/- 134 to 52 +/- 82 minutes, median 43 to 31 minutes p<0.01), and door-to-balloon time (134 +/- 146 to 84 +/- 40 minutes, median 85 -75 minutes p=0.03). Conclusion: By creating a chief complaint-based cardiac triage protocol and by streamlining ECG completion, walk-in STEMI patients are systematically processed through the ED. This is not only associated with a decrease in door-to-balloon time, but also a decrease in the variability of the time sensitive intervals of door-to-ECG and ECG-to-balloon time.