Reducing time to reperfusion for ST elevation myocardial infarction patients by a simple process change in the Emergency Department

Abstract

Current reperfusion guidelines from the European Society of Cardiology (ESC) recommend that First Medical Contact to Balloon times (FMC-B) for ST elevation myocardial infarction (STEMI) should not exceed 120 minutes. Many factors can cause delay in door to balloon times for patients suffering from STEMI. Previous studies have found that longest times for FMC-B occur if the patient presents initially to a non-percutaneous intervention (PCI) capable hospital. As a non-PCI capable site we looked at ways of reducing FMC-B times. Audit revealed that registration to electrocardiogram (ECG) times were sometimes prolonged due to undertriage, long waiting times and lack of space and staff to record an ECG, resulting in some prolonged FMC-B times.To address this, we have changed the system so that patients bypass triage and go directly to a dedicated investigation cubicle for an ECG. The patient books on at reception with chest pain and is immediately directed to the investigation cubicle. The ECG is reviewed immediately and the patient is either kept in the department for further management or allowed back to the waiting room to await triage if the ECG is non-diagnostic and history not worrying.Data on patients presenting with STEMI on the initial ECG were collected for one year pre-intervention (n =21 )and one year post-intervention (n=17). The median FMC-B time for the pre-intervention group was 108.5 minutes (IQR 96 – 143.5). Median FMC-B time for the post-intervention group was 82 minutes (IQR 66.5 - 93.5).This is a simple, low-cost intervention which could be transferable to other sites who have an interest in reducing FMC-B times. It is necessary to have a key person to carry out audit of all potential areas of delay, and a collaborative, multidisciplinary approach to making change to improve quality of care.