Failure to improve door-to-needle time by switching to emergency physician-initiated thrombolysis for ST elevation myocardial infarction

INTRODUCTION: 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.
OBJECTIVES: 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.
METHODOLOGY: 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.
KEYWORDS: Accident & Emergency Medicine; Quality improvement
Study site: Emergency department, University Malaya Medical Centre, Kuala Lumpur