The workgroup members comprised of cardiologists, Emergency Department physicians, nurses and quality management staff:

Kadir HA, Ling ML - Quality Management, Singapore Health Services
Wong P, Kwok B, Chua T, Kwok V, Amat Z, Koh TH - Cardiology, National Health Centre
Rabind AC, Lim SH - Department of Emergency Medicine, Singapore General Hospital

Our hospital offers 24-hour primary angioplasty for patients with acute myocardial infarction. A working committee was set up to identify time taken for individual steps and to institute measures to reduce the door-to-balloon time.

• To evaluate prospectively the causes of delay for patients with acute myocardial infarction requiring primary angioplasty upon arrival at the Emergency Department (ED).
• To institute recommendations to reduce delays and analyse the impact of recommendations to reduce the door-to-balloon time.

• Analysis of individual delay points in the workflow from ED to Cardiac Catheterisation Laboratory (CCL) 
• Focal group discussion on measures to eliminate delay points to reduce door-to-balloon time

A prospective survey of the door-to-balloon time was undertaken from Oct to Dec 2002. The survey covered 43 patients. Data collected was analysed and the following corrective measures were taken to improve door-to-balloon time:

• Educated staff on importance of quick response on good clinical outcome.
• Screened patients for chest pain at ED registration counter.
• Used clipboard with digital clock for event log from time of diagnosis at ED to arrival at CCL.
• Synchronised digital clock with clock at CCL.
• Developed flowchart with timelines for each step of the process to achieve American College of Cardiology/ American Heart Association (ACC/AHA) guidelines for median door-to-balloon time of 90 minutes.
• Revised survey form to add remark column.

After recommendations were instituted, a survey was conducted from January to April 10, 2003, using revised survey form covering 74 patients. Median door-to-balloon time was reduced from 146 (pre-intervention) to 104 minutes (p<0.01). Primary angioplasty was suspended due to SARS outbreak.

Primary angioplasty for acute myocardial infarction is a multi-disciplinary process requiring cooperation and communication between ED and Cardiology staff. Identification of individual delay points by a multi-discipline workgroup using an improved workflow process to improve speed of reperfusion of the infarct related artery.

Halimahton Kadir
halimahton.abd.kadir@singhealth.com

[[Also see the Survey Form that the team developed for evaluating individual timings from the ED to the cardiovascular laboratory.]]