title: Quality improvement in the door-to-balloon times for ST-elevation myocardial infarction patients presenting without chest pain.
abstract: OBJECTIVE
  To assess a quality improvement initiative aimed at minimizing door-to-balloon (DTB) times for ST-elevation myocardial infarction (STEMI) patients presenting without chest pain.
  
  
  BACKGROUND
  Timely percutaneous coronary intervention (PCI) is the cornerstone of STEMI care. The absence of chest pain delays PCI. Improvements in DTB times may need to focus on atypical presentation patients.
  
  
  METHODS
  We compared DTB times on all STEMI patients admitted through the emergency department who underwent PCI before (Phase I; October 2004-June 2007) and after (Phase II; July 2007-October 2009) the quality improvement effort, which mandated rapid electrocardiogram (ECG) triage for an expanded list of presenting symptoms.
  
  
  RESULTS
  In Phase I (69 patient, 60 with chest pain), patients with chest pain had a shorter mean time to first ECG (ECG Interval) by 32.0 min (P < 0.01) and nonsignificantly faster mean DTB time by 42.0 min (P = 0.07) compared to patients who presented without chest pain. In Phase II (62 patients, 56 with chest pain) compared to Phase I, mean ECG interval decreased by 44 min (P = 0.02) and mean DTB time by 99 min (P = 0.01) in patients without chest pain, eliminating the differences in ECG intervals between typical and atypical presentations (12 min vs. 11 min, P = 0.91). Multivariable analysis controlling for on/off hours and patient characteristics confirmed these findings.
  
  
  CONCLUSIONS
  A simple modification of emergency room ECG triage protocol, which expands indications for rapid ECG performance, was successful in improving rapid reperfusion for patients with STEMI presenting without chest pain.
authors: Cornell University, Division of Cardiology, Department of Medicine, Weill Medical College, New York, New York, USA.
authors: William B
authors: WB
authors: Borden
authors: Michelle M
authors: MM
authors: Fennessy
authors: Anne M
authors: AM
authors: O'Connor
authors: Robert A
authors: RA
authors: Mulliken
authors: Linda
authors: L
authors: Lee
authors: Sandeep
authors: S
authors: Nathan
authors: Jearlyn
authors: J
authors: Nichols
authors: John J
authors: JJ
authors: Lopez
mesh_terms: D000046:Academic Medical Centers; D000368:Aged; D000787:Angina Pectoris / Q000175:diagnosis / Q000209:etiology; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000592:standards; D016009:Chi-Square Distribution; D002641:Chicago; D016208:Databases, Factual; D004562:Electrocardiography / Q000592:standards; D004636:Emergency Service, Hospital / Q000592:standards; D005260:Female; D006297:Health Services Accessibility / Q000592:standards; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D011237:Predictive Value of Tests; D015397:Program Evaluation; D058996:Quality Improvement / Q000592:standards; D013997:Time Factors; D016896:Treatment Outcome; D014218:Triage / Q000592:standards; D057188:Workflow