Improving Door-to-ECG Time at a Quaternary Care Emergency Department

Timely diagnosis of ST-segment elevation myocardial infarction (STEMI) in the emergency department (ED) is dependent on electrocardiogram (ECG) completion. The American Heart Association recommends ECG testing within 10 minutes of arrival for patients with symptoms concerning for acute coronary syndrome. The authors aimed to increase the percentage of patients with door-to-ECG (DTE) times of < 10 minutes from 53.7% to > 75%.

We initiated a quality improvement project at an academic, quaternary care ED in June 2022. Patients included were adults (age > 30 years) who presented as walk-ins to ED triage with chest pain and received a cardiac troponin order. The primary measure was the percentage of patients with an ECG completed within 10 minutes of registration. Secondary measures included mean DTE time and mean time to STEMI activation. Statistical process control charts were used to analyze intervention impact.

Successful completion of ECGs within 10 minutes increased from 53.7% to 80.0% despite rising patient volumes. Three separate centerline shifts were associated with three interventions: (1) physical relocation of a pivot nurse to identify patients on arrival and dedicated space for rapid ECG acquisition; (2) staff education and recognition of high performers; (3) increased waiting room monitoring staff. DTE time was monitored for one year with no additional interventions, and the centerline decreased to 71.3%.

The authors used rapid Plan-Do-Study-Act (PDSA) cycle changes to improve DTE within 10 minutes to > 80% before declining to 71.3% during the maintenance phase. Modification of nursing roles and positions, staff education, recognition of high performers, and increased staffing were drivers of improvement. These improvements are translatable to other departments seeking to improve DTE metrics and may be largely sustained without active surveillance or additional interventions.