The "door-to-needle blitz" in acute myocardial infarction: the impact of a CQI project.
BACKGROUND
A continuous quality improvement (CQI) project was conducted at Soroka Medical Center in Beer-Sheva, Israel, in an effort to identify and address causes of delays in thrombolytic therapy in patients arriving at a high-volume (160,000 patients per year) emergency department with acute myocardial infarction and thereby reduce the "door-to-needle time" (DTNT). The study had four phases: preintervention survey, peri-intervention process redesign, postintervention evaluation, and follow-up evaluation. CQI TEAM: The CQI team followed a seven-step protocol: problem definition, present-state screening, factors analysis, solution development, outcome evaluation, standardization, and conclusions.


RESULTS
A DTNT of 45 minutes was considered acceptable for this data set, and accordingly, patients were divided into an "early" group (n = 50, DTNT < 45 minutes), and a "late" group (n = 50, DTNT > or = 45 minutes). After the CQI intervention, the mean DTNT decreased from 61.8 +/- 32.5 (mean +/- standard deviation) to 47.6 +/- 18.5 minutes (p < 0.029). The prolonged DTNT time intervals of the late versus the early groups was primarily due to extended decision-making time (36.0 +/- 22.7 versus 13.6 +/- 6.7 minutes, p < 0.003), followed by time until therapy was initiated (26.2 +/- 14.2 versus 11.1 +/- 5.8 minutes, p < 0.002).


CONCLUSIONS
Results suggest that the 30-minute DTNT suggested by the American College of Cardiology/American Heart Association is appropriate for patients with a clear diagnosis and no contraindications for thrombolysis, but when the risk-benefit ratio of thrombolytic therapy raises concerns, a 45- to 60-minute DTNT may still be acceptable. Further CQI projects should address technical triage of simple cases and clinical estimation of risk-benefit ratio in complicated patients.
Gilutz
H
H
Cardiology Department, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel. gilutz@bgumail@bgu.ac.il
Battler
A
A
Rabinowitz
I
I
Snir
Y
Y
Porath
A
A
Rabinowitz
G
G
D004636:Emergency Service, Hospital / Q000592:standards*; D006801:Humans; D007557:Israel; D009203:Myocardial Infarction / Q000188:drug therapy*; D015397:Program Evaluation; D015912:Thrombolytic Therapy / Q000592:standards / Q000706:statistics & numerical data*; D013996:Time and Motion Studies; D017749:Total Quality Management / Q000379:methods / Q000458:organization & administration*; D014218:Triage