Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India.
Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
BMJ Open Qual. 2022 Aug;11(Suppl 1). doi: 10.1136/bmjoq-2021-001764.
ST-elevation myocardial infarction (STEMI) is a highly time-sensitive and life-threatening condition. Early recognition and timely management are challenging in a busy emergency department (ED), especially in low/middle-income countries where emergency systems are often fragmented. The aim of our quality improvement (QI) project was to increase the percentage of patients with STEMI undergoing primary percutaneous coronary intervention (PCI) with door to balloon (D2B) time of <90 min by 30% over 12 months.
As part of the first step in QI, baseline data were collected at different points in the process of care. Using process maps and fishbone analysis, delays in patient registration, ECG and communication with cardiology were identified as some bottlenecks, and change ideas were tested using plan-do-study-act cycles using point-of-care QI methodology. The majority of the change ideas focused on interventions in the ED like strengthening triage, training frontline staff, early diagnosis and quick transportation of patients.
During the baseline phase, 22.22% of patients were found to have a D2B time of <90 min. We achieved an increase of 47.78% in patients receiving PCI within 90 min and hence increased to 70% at the end of the intervention phase. Data collected for 4 months after the intervention phase were found to have sustained the effort.
Significant improvement in the door to reperfusion time resulted from a meticulous assessment of emergency care processes by drawing process flow chart and implementation of change ideas like introduction of fast-track policy for patients with chest pain, reducing staff turnover in the triage area, formal training of staff, continuous engagement with cardiology team and by interchanging of processes which led to a reduction in time to ECG.
ST 段抬高型心肌梗死（STEMI）是一种高度时间敏感且危及生命的病症。在繁忙的急诊科（ED）中，早期识别和及时管理具有挑战性，特别是在紧急系统通常碎片化的中低收入国家。我们质量改进（QI）项目的目的是在 12 个月内将接受直接经皮冠状动脉介入治疗（PCI）的 STEMI 患者的门球时间（D2B）<90 分钟的比例提高 30%。
作为 QI 的第一步的一部分，在护理过程的不同点收集基线数据。使用流程图和鱼骨图分析，确定患者登记、心电图和与心脏病学沟通方面的延迟是一些瓶颈，并使用即时护理 QI 方法的计划-执行-研究-行动循环测试变更思路。大多数变更思路都集中在 ED 干预方面，如加强分诊、培训一线工作人员、早期诊断和快速运送患者。
在基线阶段，发现 22.22%的患者 D2B 时间<90 分钟。我们实现了接受 PCI 的患者在 90 分钟内增加了 47.78%，因此在干预阶段结束时增加到了 70%。干预阶段结束后收集的 4 个月的数据显示，努力得到了维持。
通过绘制流程图和实施变更思路，如为胸痛患者引入快速通道政策、减少分诊区员工流动、对员工进行正式培训、与心脏病学团队持续合作以及交换流程，显著缩短了心电图时间，从而改善了再灌注时间的门控。
