title: Failure to improve door-to-needle time by switching to emergency physician-initiated thrombolysis for ST elevation myocardial infarction.
abstract: BACKGROUND
  Achieving target door-needle times for ST elevation myocardial infarction remains challenging. Data on emergency department (ED) doctor-led thrombolysis in developing countries and factors causing delay are limited.
  
  
  OBJECTIVE
  To assess the effect on door-needle times by transferring responsibility for thrombolysis to the ED doctors and to identify predictors of prolonged door-needle times.
  
  
  METHODS
  Data on medical on-call team-led thrombolysis at a tertiary Asian hospital were prospectively collected from May 2007 to Aug 2008 (1st study period). In September 2008, ED doctors were empowered to perform thrombolysis. The practice change was accompanied by new guidelines, tick chart implementation, and training sessions. Data were then consecutively collected from September 2008 to May 2009 (2nd study period). Door-to-needle times for the 1st and 2nd study periods were compared. All cases were analysed for factors of delay by multiple logistic regression.
  
  
  RESULTS
  297 patients were thrombolysed, 169 by the medical on-call team during the 1st study period and 128 by the ED doctors during the 2nd study period. Median door-needle times were 54 and 48 min, respectively (p=0.76). Significant delays were predicted by 'incorrect initial ECG interpretation' (adjusted OR (aOR) 14.3), 'inappropriate triage' (aOR 10.4) and 'multiple referrals' (aOR 5.9). No cases of inappropriate thrombolysis were recorded.
  
  
  CONCLUSIONS
  Transfer of responsibility for thrombolysis to the ED doctors did not improve door-needle times despite measures introduced to facilitate this change. Key causative factors for this failure were identified.
authors.affiliation: Department of Emergency Medicine/Cardiology, Pusat Perubatan Universiti Malaya, Lembah Pantai, Kuala Lumpur 59100, Malaysia. alexanderloch@gmx.de
authors.forename: Alexander
authors.initials: A
authors.lastname: Loch
authors.forename: Tint
authors.initials: T
authors.lastname: Lwin
authors.forename: Idzwan Mohd
authors.initials: IM
authors.lastname: Zakaria
authors.forename: Imran Zainal
authors.initials: IZ
authors.lastname: Abidin
authors.forename: Wan Azman
authors.initials: WA
authors.lastname: Wan Ahmad
authors.forename: Oliver
authors.initials: O
authors.lastname: Hautmann
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003657:Decision Making; D003906:Developing Countries; D004632:Emergency Medical Services / Q000592:standards*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008296:Malaysia / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000628:therapy*; D010343:Patient Admission; D062645:Percutaneous Coronary Intervention / Q000592:standards*; D010865:Pilot Projects; D017410:Practice Guidelines as Topic; D019984:Quality Indicators, Health Care; D015912:Thrombolytic Therapy / Q000592:standards; D061665:Time-to-Treatment / Q000592:standards; D016896:Treatment Outcome; D014218:Triage / Q000592:standards*
keywords: Accident & Emergency Medicine; Quality improvement