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The use of audit to set up a thrombolysis programme in the accident and emergency department
1Accident and Emergency Department, Gloucester Royal Hospital.
Insights
Moving thrombolysis to the A&E department significantly reduced door-to-needle time for acute myocardial infarction patients. This initiative improved treatment rates and demonstrated the effectiveness of an audit-driven approach in a district general hospital.
Area of Science:
- Cardiology
- Emergency Medicine
- Healthcare Management
Background:
- The thrombolysis service at Gloucester Royal Hospital had a median door-to-needle time of 110 minutes.
- Only 58% of acute myocardial infarction patients were receiving thrombolysis.
- The existing thrombolysis program was based in the Coronary Care Unit (CCU).
Purpose of the Study:
- To reduce the door-to-needle time (DTN) for thrombolysis to 30 minutes.
- To increase the proportion of acute myocardial infarction patients receiving thrombolysis to 70%.
- To achieve these goals by relocating the thrombolysis program to the Accident and Emergency (A&E) department.
Main Methods:
- An audit process was employed to identify performance issues and set standards.
- The thrombolysis program was moved from the CCU to the A&E department.
- Data on DTN, overall delay time, and thrombolysis rates were collected for 946 patients presenting with chest pain.
Main Results:
- Median DTN was reduced to 38 minutes (p < 0.0006).
- The thrombolysis rate for acute myocardial infarction patients increased to 68% (p < 0.05).
- 70% of patients received thrombolysis within 6 hours of symptom onset, with 90% receiving it within 12 hours.
Conclusions:
- An Accident and Emergency (A&E) department-based thrombolysis program is effective in a District General Hospital.
- The audit process facilitated the acquisition and securing of funding for the program.
- Adequate staffing and appropriate education are crucial for successful implementation of healthcare changes.
Objective:
To improve the thrombolysis service offered by Gloucester Royal Hospital, by reducing the "door to needle time" (DTN) to 30 min (from a median of 110 min), and increasing the proportion of patients with acute myocardial infarctions receiving thrombolysis to 70% (from 58%). This would be achieved by moving the thrombolysis programme from the coronary care unit (CCU) to the accident and emergency (A&E) department.
Design:
The process of audit was used to identify an area of poor performance, set standards, acquire funding, demonstrate achievement, and subsequently secure recurrent funding.
Setting:
Gloucester Royal Hospital.
Subjects:
946 patients presenting consecutively to the A&E department with non-traumatic chest pain between August 1993 and March 1994.
Main Outcome Measures:
DTN, overall delay time, and acute myocardial infarction thrombolysis rate.
Results:
946 patients were assessed over the eight month period, of whom 266 (28%) had suffered an acute myocardial infarction; 182 (68%) received thrombolysis (compared to 58% previously P < 0.05). Median DTN was reduced to 38 min (v 110 min previously, P < 0.0006). 127 (70%) patients received thrombolysis in the A&E department, and 55 (30%) in the CCU. Median overall delay time between onset of pain and thrombolysis was 3 h 35 min; 70% of patients received thrombolysis within 6 h of onset of symptoms and 90% within 12 h. Re-audit has subsequently shown maintenance of improvement.
Conclusions:
An in-house A&E based thrombolysis programme works in the District General Hospital setting; the process of audit can be used to acquire, and subsequently secure, funding for the project. The key to successful implementation of change is sensible resource allocation into adequate staffing and appropriate education.