Improving Door-to-Drug time and ST segment resolution in AMI by moving thrombolysis administration to the Emergency Department

Abstract

Background. We describe a combination of measures to reduce Door-to-Drug (DTD) time and improve the Emergency Department (ED) management of ST elevation MI (STEMI): appointment of a Cardiology Nurse Specialist, application of the American College of Cardiology and the American Heart Association (ACC/AHA) guidelines, changing the site of thrombolysis from the CCU to the ED, the introduction of a single bolus thrombolytic agent. Methods. The 12-month period before and after the introduction of the measures were retrospectively reviewed. One hundred and sixty patients were discharged from the CCU with the diagnosis of myocardial infarction confirmed by ECG and enzyme criteria. Eighty patients had STEMI and fulfilled criteria for thrombolytic therapy at the time of presentation to hospital. A full data set was available on 35/38 of patients in the 12 months prior to the measures (Year 1), and 39/42 in the 12 months subsequent (Year 2). Results. Median DTD time fell from 80 to 22 min after institution of the measures. Median Pain-to-Drug time also fell from 270 to 140 min. Thrombolytic agent given in the ED rose from 3% in Year 1, to 72% in Year 2. IV β-blocker administered in the ED rose from 12% to 79%, resulting in median time to receiving IV β-blocker falling from 63 to 19 min. Elevated ST segments resolved by ⩾70% in <2 h in 53% of Year 2 patients, compared with 23% of Year 1 patients. Combined major in-hospital adverse clinical events were reduced from 49% to 15%. Conclusion. This combination of measures reduces DTD time, improves speed to delivery of important concomitant medications, and significantly improves the time to ST segment resolution and outcome in STEMI.