The "door-to-needle blitz" in acute myocardial infarction: the impact of a CQI project.

BACKGROUND: A continuous quality improvement (CQI) project was conducted at Soroka Medical Center in Beer-Sheva, Israel, in an effort to identify and address causes of delays in thrombolytic therapy in patients arriving at a high-volume (160,000 patients per year) emergency department with acute myocardial infarction and thereby reduce the "door-to-needle time" (DTNT). The study had four phases: preintervention survey, peri-intervention process redesign, postintervention evaluation, and follow-up evaluation. CQI TEAM: The CQI team followed a seven-step protocol: problem definition, present-state screening, factors analysis, solution development, outcome evaluation, standardization, and conclusions. RESULTS: A DTNT of 45 minutes was considered acceptable for this data set, and accordingly, patients were divided into an "early" group (n = 50, DTNT < 45 minutes), and a "late" group (n = 50, DTNT > or = 45 minutes). After the CQI intervention, the mean DTNT decreased from 61.8 +/- 32.5 (mean +/- standard deviation) to 47.6 +/- 18.5 minutes (p < 0.029). The prolonged DTNT time intervals of the late versus the early groups was primarily due to extended decision-making time (36.0 +/- 22.7 versus 13.6 +/- 6.7 minutes, p < 0.003), followed by time until therapy was initiated (26.2 +/- 14.2 versus 11.1 +/- 5.8 minutes, p < 0.002). CONCLUSIONS: Results suggest that the 30-minute DTNT suggested by the American College of Cardiology/American Heart Association is appropriate for patients with a clear diagnosis and no contraindications for thrombolysis, but when the risk-benefit ratio of thrombolytic therapy raises concerns, a 45- to 60-minute DTNT may still be acceptable. Further CQI projects should address technical triage of simple cases and clinical estimation of risk-benefit ratio in complicated patients.