To improve the timeliness of the diagnosis of ST Elevation Myocardial infarction in patients presenting to Gloucester Emergency Department with chest pain

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Background & Problem

ST elevation Myocardial infarction (STEMI) is a life-threatening condition, for which prompt recognition and reperfusion (within 120 minutes) reduces myocardial death. Several patient safety reports have flagged up the delays in diagnosis in our Emergency department (ED) and previous audits have confirmed our failure to meet the desired ‘time to ECG’ target of 10 minutes.

Aim

Within 3 months to reduce the time to ECG by 20% and thus speed up STEMI diagnosis for patients presenting to Gloucester ED with chest pain.

Method

Primary Outcome measure: Time to ECG.

Process measures: Time to Triage and Doctor review.

Indicators of presumed cardiac risk were gauged from the allocated triage category and whether the notes reported a cardiac history or ‘cardiac’ chest pain.

External factors that were hypothesised to influence the results included ED crowding, mode of arrival and time of day were also collected.

The data of chest pain patients presenting to Gloucester ED were plotted on a run chart and reviewed on a fortnightly basis. From these the following priorities for change were set:

• PDSA 1 - Formation of a ECG QIP team
• PDSA 2 - Change of triage process
• PDSA 3 - An ECG room to be kept available for corridor patients (with corresponding poster)
• PDSA 4 - Nursing education session
• PDSA 5 - Doctors education sessions (Induction and Mortality & Morbidity meeting)

Results

There was a reduction of the average time to ECG from 52 minutes to 32 minutes (a reduction of 38%). Improvement was particularly apparent in those patients who were allocated to wait in the corridor, reducing time to ECG for them from an average of 55 minutes to 31 minutes (a reduction of 44%). As a consequence, a larger proportion of patients had an ECG within the window of feasibility to obtain Primary PCI within the target of 120mins: 89% post-intervention verses 74% prior to intervention.

Implications

The results appear promising but the sustained effect of ECG timings and its translation to STEMI treatment will require continual monitoring. Further work needs to be done to reduce the time to ECG to the desired 10 minutes. The next patient subgroup to focus on are those who self-present to the department.