Emergency department triage redesign: can elements designed to improve department flow reduce door-to-ECG times in self-presenting ED patients suspected of myocardial infarction?

HHS-SM-Reducing Door-to-ECG Times


Introduction: ST-Elevation Myocardial Infarction (STEMI) represents irreversible necrosis of myocardial tissue. Prompt time-to-reperfusion in these patients is paramount in reducing morbidity and mortality. This concept, time-to-reperfusion, is the principle focus for improving STEMI care. Prioritizing diagnosis in patients with high-risk cardiac features through rapid electrocardiogram (ECG) is essential, with gold standard time-to-ECG benchmarked at 10-minutes. While substantial literature is established for pre-hospital ECG interventions, there is a paucity of intervention data for self-presenting patients. While evaluating these times within our department, we conducted a redesign of the triage process. These included nurses becoming the first contact and the addition of an extra triage nurse. These changes provided the opportunity to evaluate whether the redesign elements of the triage system meant to improve department flow could improve other patient-centered outcomes, namely time-to-ECG. 

Methods: The first fifty self-presenting patients designated as “cardiac chest pain” in the month preceding changes to the triage system were analyzed to create a baseline time-to-ECG value. Following the alteration to our triage system, three samples of the first 50 patient's time-to-ECG were collected at two, four and six months post-intervention and compared to pre-intervention via non-paired t-test. Data was further stratified into percentages of patients receiving an ECG within 10-minute intervals starting with 0-10 minutes. Proportions pre and post intervention were then compared using z-scores. 

Results: A baseline pre-intervention time-to-ECG value of 26.6 minutes was established. Average post-intervention time-to-ECG was significantly reduced at 15.6min with a mean difference of -11.0min ± 3.0 (95% CI -16.0 – (-5.0)). Interestingly, the proportion of ECGs performed under 20 minutes rose significantly from 58% to 81% (z=−3.2, p < 0.001) while the increase in proportion of ECGs performed under 10 minutes from 26% to 37% was not statistically significant (z=−1.4). 

Conclusion: The results of this analysis suggest that the addition of an extra triage nurse coupled with changing first point of ED contact from the business clerks to triage nurses significantly reduced mean time-to-ECG in self-presenting patients with chest pain deemed high risk for cardiac causes. Additionally, these changes significantly increased the proportion of ECGs performed within 20 minutes of ED arrival in these patients.

Authors: M. Hewitt, B. Forestell, S. Mondoux

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