Vroom, Vroom!! Improving Door to ECG Times in a Large, High-volume Emergency Department

Aim: : Obtaining an ECG within 10 minutes of arrival to diagnose STEMI is critical to early identification, intervention and best patient outcomes.
This ED saw an increase in Door to ECG (DTE) times related to additional infection prevention screenings and increase in patient volume. Median DTE times were as high as 12 minutes. Compliance for ECGs being completed under 10 minutes was as low as 45%.
The aim of this quality improvement project was to improve door to ECG times.

Framework:: This project utilized the IHI Model for Improvement and PDSA cycles.

Setting:: Urban Level I Academic Medical Center

Stakeholder Team:: The project team was multi-disciplinary and included bedside nursing staff, ED Nursing Leadership (Assistant Nurse Manager, Clinical Nurse Specialist), Physicians (Quality and Safety Medical Directors), and a Quality and Patient Safety Advisor.
Physician and Nursing leaders facilitated project meetings to ensure forward movement of initiatives. Provided departmental leadership support to ensure challenges and barriers to change were addressed.
The CNS and Assistant Nurse Manager led the implementation of initiative. Created and delivered education to staff. Monitor data daily/weekly/monthly. Report out to divisional executives and leadership.
Bedside nursing staff were experts on day to day practice challenges/barriers to success. Championed improvement initiatives while on shift. Presented quality improvement work at shared governance meetings.
Quality and Patient Safety Advisor facilitated the PDSA cycle review process.

Methods: : Median DTE times were as high as 12 minutes. Compliance for ECGs being completed under 10 minutes was as low as 45%. This large, high-volume, chest pain accredited, academic medical center initiated a quality improvement project to improve these metrics in June 2022. Project involved rapid cycle changes that included staff re-positioning in our ED entrance, reestablishing role responsibilities back to pre-pandemic standards, and daily communication to staff on previous days metrics. PIVOT Nurse/Medic role to assist with early screening and recognition of patients needing an ECG based on established criteria was used. At the implementation of this project, that PIVOT role location and responsibility was shifted back to pre-pandemic expectations. Development of a recognition and reward program for the weekly fastest ECG staff performers. Weekly fastest champions are recognized through email, posting in Triage, and digital boards. Weekly high performers receive a lapel pin to recognize their achievement.

Outcomes:: Since implementation of this project in June 2022, this ED has seen a statistically significant improvement in DTE times. Median DTE times have been consistently at 7 minutes since this implementation of this project. Compliance for arrival to ECG completed under 10 minutes has increased from 45% to 77% in just 7 months. Current fasted ECG time is 2 minutes. All of these improvements have been during a time of increasing and record patient volume for this organization.

Implications:: Key to successes are staff engagement and motivation to be a high performer. Reward and recognition was a great motivator for staff engagement in a friendly competition. Identification, re-education and re-establishment of specific role responsibilities to allow for early intervention.