Australasian Emergency Care 24 (2021) 141–146 Contents lists available at ScienceDirect Australasian Emergency Care journal homepage: www.elsevier.com/locate/auec Research paper The importance of organizational variables in treatment time for patients with ST-elevation acute myocardial infarction improve delays in STEMI Gemma Berga Congost a,b,∗ , Salvatore Brugaletta c,d , Jonatan Valverde Bernal a,b , Adrián Márquez López a,b , Judit Ruiz Gabalda a , Joan Garcia-Picart a , Mireia Puig Campmany b,e , Maria Antonia Martinez Momblan f,g a Interventional Cardiology Department, Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain b Sant Pau Biomedical Research Institute, Barcelona, Spain c Interventional Cardiology Department, Cardiology, Hospital Clinic, Barcelona, Spain d Biomedical Research Institute IDIBAPS, Barcelona, Spain e Emergency Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain f University of Barcelona Faculty of Medicine and Health Sciences, Fundamental Care and Medical-Surgical Nursing Department, School of Nursing, Barcelona, Spain g Research Networking Centre of Rare Diseases, CIBER-ER, Unit 747, Spain a r t i c l e i n f o a b s t r a c t Article history: Background: The time between arrival at the emergency department (ED) and balloon (D2B) in STEMI is Received 18 June 2020 one of the best indicators of the quality of care. Our aim is to describe treatment times and evaluate the Received in revised form 9 October 2020 causes of delay. Accepted 12 October 2020 Methods: This is an observational retrospective study, including all consecutive STEMI code patients ≥18 years old treated in the ED from 2013 to 2016.All the patients were stratified into two groups: delayed Keywords: group with D2B > 70 min and non-delayed ≤70. The primary variable was D2B time. Myocardial infarction Findings: In total 327 patients were included, stratified according to their D2B as follows: 166 (67·48%) STEMI Nurses in the delayed group and 80 (32·52%) in the non-delayed group. The delayed group was older (p = 0·005), Triage with more females (p = 0·060) and more atypical electrocardiogram (ECG) STEMI signs or symptoms (p = 0·058) (p = 0·087). Predictors of shorter D2B time were: typical STEMI ECG signs and short training sessions for nurses on identifying STEMI patients. Interpretation: There are delays particularly in specific groups with atypical clinical presentations. Short training sessions aimed at emergency nurses correlate with shorter delay. This suggests that continuing training for emergency nurses, along with organizational strategies, can contribute to increasing the quality of care. Clinical trial number: NCT04333381 © 2020 The Authors. Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). Introduction infarction (MI), with primary angioplasty (PPCI) being the reperfu- sion therapy of choice [2,3]. Ischemic heart disease is the primary cause of death in the world, In 2008, with the aim of improving MI treatment, the European accounting for up to 20% of deaths in Europe [1]. The most common Stent for Life initiative was launched, which strove to facilitate the clinical presentation, with the worst prognosis, is acute myocardial implementation of MI healthcare networks and increase the use of early PPCI as a reperfusion treatment [4]. In the country of study, programs were created under the same guidelines [5], which classifies the treatment given to each patient in a reference hospital [6] and is based on the European Soci- ∗ Corresponding author at: Interventional Cardiology, Hospital de la Santa Creu i ety of Cardiology’s (ESC) clinical guidelines for ST elevation acute Sant Pau, 89 Sant Quintí St, Barcelona 08041, Spain. coronary syndrome (STEMI). The guidelines emphasize that time E-mail address: gberga@santpau.cat (G. Berga Congost). https://doi.org/10.1016/j.auec.2020.10.001 2588-994X/© 2020 The Authors. Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). G. Berga Congost et al. Australasian Emergency Care 24 (2021) 141–146 intervals are an optimal healthcare quality indicator in STEMI into the non-delayed diagnosis group (FMC-ECG ≤ 10 min) and treatment, being directly correlated to subsequent morbidity and the delayed diagnosis group (FMC-ECG > 10 min). mortality [7,8]. Any delay in the patient treatment system reflects - Quality variables: the quality indicators for STEMI timings rec- the centre’s response and organization capacity, as well as various ommended in the current guidelines were used [7]. sociodemographic and clinical factors [7–15]. Therefore, the establishment of systematic, organized PPCI pro- Organizational variables: All these variables were positively grams has a direct impact on healthcare quality and the patients’ coded from the start date of the organizational measurement pro- prognosis [16]. cess. The emergency management (ED) of the hospital is based on a continuous improvement program with respect to the quality - Creation of the MI Code Committee of the hospital: a multidisci- of the healthcare processes, using the Plan-Do-Check-Act (PDCA) plinary working group that regularly evaluates delays and designs methodology, also known as the Deming Cycle [17]. In particular, improvement strategies. organizational, training and management interventions have been - Institutional protocols: Drafting the hospital’s unified and shared implemented with the aim of reducing treatment delays for STEMI STEMI protocols. patients. - Intra-hospital transfer management: Organizational changes in Our objective is to describe response times for myocardial the management of transfers, coordinated directly by the Emer- infarctions in the case of patients who go directly to the ED of our gency Department. hospital, evaluating delays between arrival time and opening the - Short reinforcement sessions: Short training sessions were run artery in correlation to sociodemographic, clinical and result fac- for emergency nurses. The education intervention takes a mixed tors, using the Plan-Do-Check-Act methodology to implement new training approach (group and individualized), that is ongoing and continuous improvement strategies. regular over time, with the aim of maintaining the peak effect of the professionals’ knowledge. The different parts of the training program can be summarized as follows: Methods With respect to the group intervention, short reinforcement and Study design and population update educational sessions on the MI Code were run, aimed at all emergency professionals, on a twice-yearly basis. The methodol- An observational retrospective study conducted in the emer- ogy of these sessions was based on the analysis and discussion of gency department and haemodynamic laboratory of the hospital complex and contentious clinical case studies. At the same time, the between January 2013 and December 2016. supervising nurse or the MI code supervisor ran short 15-minute The study population were all adult patients with suspected sessions twice a month on key aspects of STEMI identification, STEMI activated consecutively as an MI code by the Emergency Ser- workshops and consolidation activities, for all emergency-nursing vice, who meet the following inclusion criteria: patients ≥18 years shifts. All the contents included in these sessions were the contents old, admitted to the ED of the hospital. Patients identified as STEMI specified in the STEMI clinical practice guidelines of the ESC. on a pre-hospital basis were excluded as they are transferred by In terms of the individualized education intervention, within the ambulance or helicopter directly to the Haemodynamic Unit by the framework of the MI Code Committee, patients whose treatment emergency medical services, bypassing the ED to prevent delays. had been delayed were identified, with an evaluation of possible In addition, patients who did not undergo a coronary angiography causes and emergency professionals who participated in the treat- and pregnant women were excluded. ment of these patients. Areas for improvement were specified. The supervising nurse or the MI code supervisor then contacted the emergency nurse involved in the care of these patients. The nurse Procedures then took part in an individualized intervention based on a reflexive analysis of the case, the identification of errors and the specification All the clinical variables were gathered retrospectively using of areas for improvement. In addition, they were given personalized the Data Collection Register, based on the recommendations of the knowledge based on their needs. The contents of the individualized clinical guidelines of the ESC [7]. education intervention were based on the recommendations of the The main variable of the study was the time between arrival at European STEMI clinical guidelines. the ED and opening the artery (Door-to-Balloon, or D2B). An ade- All the data was collected from the information terminal of MI quate D2B time was taken to be 70 min, with 10 min between arrival Code registry, a database containing all the clinical variables and at the ED and conducting the ECG, and 60 min between diagnosis response times. and the balloon procedure, in line with the clinical guidelines of the ESC [7]. As specified in the guidelines, the sample was divided into Ethical approval two groups: the non-delayed treatment group (D2B ≤ 70 min) and the delayed treatment group (D2B > 70 min). All the variables were The study was approved by Ethics Committee of Santa Creu and compared between these two groups. Sant Pau Hospital and the reference number is IIBSP-IAM-2015-84 The following secondary variables were also taken into consid- ( version 2). erations: Statistical analysis - Intra-hospital mortality - Hospital stay With respect to analysing the data, a descriptive analysis was - False positives conducted, giving the percentage, as well as the number of cases - Response time variables: response times included in accordance for the categorical variables, the mean value with the standard with the definition in the clinical guidelines [7]. Moreover, two deviation for quantitative variables with normal distribution, and groups were compared based on the adequate time interval the median with the interquartile range in the case of quantita- between the first medical contact (FMC) and the ECG of 10 min, tive variables with non-normal distribution. Categorical variables as specified in the guidelines [7]. As such, the sample was divided were compared using the Chi-squared test or Fisher’s exact test, as 142 G. Berga Congost et al. Australasian Emergency Care 24 (2021) 141–146 Fig. 1. Flow chart. Population included in the study. D2B: door-to-balloon. ECG: electrocardiogram. ED: Emergency Department. FMC: first medical contact. MI: Myocardial infarction. applicable, while the quantitative variables were compared with who was deactivated after another diagnosis was confirmed. This the ANOVA test or Mann-Whitney U test, depending on their dis- resulted in a final sample of 327 patients. 12·8% (n = 42) of the acute tribution. MI codes activated were false positives, while 75·23% (n = 246) To evaluate the predictive factors of the time between arrival at were given primary PCI treatment. Of those, 32·52% (n = 80) were the ED and opening the artery, a linear regression analysis was car- assigned to the non-delayed treatment group (D2B ≤ 70 min) and ried out, with any variables with p < 0·10 in the univariate analysis 67·48% (n = 166) to the delayed treatment group (D2B > 70 min). being considered independent variables. Therefore, the variables Moreover, two groups were distributed based on whether or taken into consideration were the patient’s sex, age, working hours, not there was a delay in diagnosis, with 51·07% (n = 167) being chest pain in presentation, elevation of the ST segment in the ECG, assigned to non-delayed diagnosis group (FMC/ECG ≤ 10 min) and and training sessions for nurses. 48·93% (n = 160) to the delayed diagnosis group (FMC/ECG > 10 min) A 2-tailed level of significance of 5% (␣ = 0·05) was use. All analy- (Fig. 1). ses were conducted using the IBM–SPSS (V22·0) statistical package. In terms of the clinical profile, when comparing the delayed treatment groups, it was observed that patients who presented Role of the funding source with the longest delays were elderly (p = 0·005), female (p = 0·060), with atypical symptomatology and electrocardiogram (p = 0·087 The funders of the study played no role in study design, data col- and p = 0·058, respectively), and usually presented outside working lection, data analysis, data interpretation, or writing of the report. hours (p = 0·001). Moreover, the patients in the delayed treatment The corresponding author had full access to all the data in the group had a longer hospital stay (5 (3–8) day vs. 4 (3–6) days; study and had final responsibility for the decision to submit for p = 0·041) (Table 1). publication. Meanwhile, when patients were compared according the delay in diagnosis, it was observed that there was a longer delay in the case of patients who had had other medical contact before Outcomes going to the Emergency Department (p = 0·004) and in more severe cases (AMI Killip III/IV) (p = 0·006). With respect to symptomatol- Study population ogy, there was a longer delay in performing the ECG in the case of patients who did not present chest pain (p = 0·004), who were not The total population of patients activated as an MI code dur- sweating (p = 0·025) and whose first event was a syncope (p = 0·026) ing the period of study, according to the hospital’s annual report, or cardiorespiratory arrest (0·001). A higher mortality rate was was 1687 patients. Of these, 330 were patients activated from also observed in the cases with a delay in the diagnosis (p = 0·039) the ED of the hospital itself, with two patients who died at the (Table 1). door of the Haemodynamic Unit being excluded, as well as one 143 G. Berga Congost et al. Australasian Emergency Care 24 (2021) 141–146 Table 1 Baseline clinical characteristics of study participants, organizational variables and quality indicators of STEMI. The figures show n (%). Mean ± standard deviation. CRA: cardiorespiratory arrest. DLP: dyslipidemia. DM: Diabetes mellitus. ECG: electrocardiogram. ED: Emergency Department. FMC: first medical contact. GPC: General poor condition. HTA: arterial hypertension. MH: medical history. PCI: percutaneous coronary intervention. Variables STEMI Code n (%) ED/Balloon ≤ 70 min ED/Balloon >70 min p FMC/ECG ≤ 10 min FMC/ECG >10 min p Number of patients 327(100) 80(32·5) 166(67·5) 167(51·1) 160(48·9) Females 78(23·9) 12(15) 43(25·6) 0·06 36(21·6) 42(26·2) 0·320 Age (mean ± SD) 64 ± 14 61 ± 12 66 ± 14 0·005 64 ± 13 64 ± 15 0·711 HTA 198(60·6) 45(56·3) 104(61·9) 0·395 106(63·5) 92(57·5) 0·269 DLP 177(54·1) 40(50) 101(60·1) 0·133 92(55·1) 85(53·1) 0·722 DM 84(25·7) 19(23·8) 47(28) 0·481 42(25·1) 42(26·3) 0·82 Tobacco use 196(59·9) 56(70) 100(59·5) 0·239 100(59·9) 96(60) 0·618 Obesity 63(19·3) 21(26·3) 32(19·2) 0·204 31(18·6) 32(20·1) 0·721 Cardiological MH 80(24·5) 17(21·3) 37(22) 0·89 44(26·3) 36(22·5) 0·419 Killip III/IV 58(19·9) 13(16·5) 32(20·6) 0·442 21(13·5) 36(26·5) 0·006 FMC ED 184(56·3) 44(55) 103(61·3) 0·344 107(64·1) 77(48·1) 0·004 Working hours 120(36·7) 41(51·3) 48(28·6) 0·001 59(35·3) 61(38·1) 0·60 PCI 249(75·9) 80(100) 166(100) 0·139 126(75·4) 118(73·8) 0·724 Anterior ECG 132(40·4) 36(45) 69(41·3) 0·162 68(40·7) 64(40·3) 0·397 Inferior ECG 133(40·7) 38(47·5) 70(41·9) 65(38·9) 67(42·2) Lateral ECG 22(6·7) 5(6·3) 15(9) 15(9) 7(4·4) Chest pain 254(77·4) 70(87·5) 131(78·4) 0·087 141(84·4) 113(71·1) 0·004 Atypical pain 72(22·02) 10 (12·5) 36 (21·6) 0·087 26 (15·6) 46 (28·9) 0·004 Dyspnea 71(21·8) 13(16·5) 37(22·2) 0·3 34(20·5) 37(23·3) 0·543 Syncope 19(5·8) 3(3·8) 9(5·4) 0·588 5(3) 14(8·8) 0·026 Sweating 140(42·9) 38(48·1) 73(43·7) 0·518 81(48·8) 58(36·5) 0·025 Nausea/vomiting 96(29·4) 19(24·1) 58(34·7) 0·092 53(31·9) 42(26·4) 0·275 GPC/Weakness 46(14·1) 8(10·1) 21(12·6) 0·578 25(15·1) 20(12·6) 0·517 CRA 36(11) 7(8·9) 20(12) 0·465 9(5·4) 27(17) 0·001 ECG ST elevation 267(81·7) 71(89·9) 134(80·2) 0·058 135(81·3) 130(81·8) 0·919 In-hospital Mortality 38(11·6) 9 (11·3) 21 (12·5) 0·778 13(7·8) 24(15) 0·039 Hospital stay 5(3–8) 4(3–6) 5(3–8) 0·041 5(3–7) 5(3–9) 0·227 STEMI Code Committee 173(52·9) 47(58·8) 90(53·9) 0·472 88(52·7) 85(53·5) 0·89 Institutional protocols 173 (52·9) 47(58·8) 90(59·3) 0·472 88(52·7) 85(53·5) 0·89 Intra-hospital transfer management 173(52·7) 47(58·8) 90(53·6) 0·443 88(52·7) 85(53·1) 0·938 Short sessions for nurses 49(14·9) 13(16·3) 27(16·1) 0·971 21(12·6) 28(17·5) 0·212 Pain/Balloon <12 h 217(87·5) 75(93·8) 142(84·5) 0·04 117(92·1) 100(82·6) 0·024 Pain/FMC if PCI 12 h 234(94·4) 76(95) 157(94) 0·753 122(95·3) 112(93·3) 0·50 ECG/Balloon<60min 47(18·9) 36(45) 10(63) <0,001 29(22·7) 18(15) 0·188 ED/ECG < 10 min 222(67·9) 71(88·8) 95(56·5) <0,001 166(99·4) 56(35) <0,001 FCM/ECG<10min 167(51·1) 52(65) 75(44·6) 0·003 167 (100) 0(0) 0·001 Response times pain/FMC, D2B and ECG/Balloon time intervals and the total ischemia time are higher than the recommendations in the guide- The median time between arrival at the ED and opening the lines. 4) Short training sessions for emergency nurses can lead artery (ED/balloon) was 88 min (65–121). In addition, in the delayed to a reduction in the time between arrival at the ED and bal- treatment group, a greater delay was observed in all the AMI loon. response times (Table 2). The results confirm the evidence consulted on delays with Moreover, the median time between the first medical respect to sociodemographic and clinical data. As various authors contact and the electrocardiogram (FMC/ECG) was 10 min have found, our observations show that the D2B time and the MI (5–26) and the patients whose diagnosis was delayed activation code is higher in the case of women [18,19]. As other (FMC/ECG > 10 min) also had a greater delay in all the intervals authors have suggested, one of the possible causes is that women except Activation–Haemodynamics and Haemodynamics–Balloon present more atypical symptoms, resulting in a delay in diagnosis (Table 2). [7,20]. There was less adherence to the quality indicators among the The results show that atypical clinical presentation and elec- delayed treatment group and the delayed diagnosis group (Table 1). trocardiogram are causes of delay in the case of elderly patients, as observed in different studies consulted in the literature [21,22]. Treatment delay predictive factors The results are also in line with previous observations, such as the The independent predictive factors of the time between arrival fact that patients who suffer a longer delay present outside work- at the ED and opening the artery (D2B) were the presence of ele- ing hours, are more serious and have had medical contact prior to vation of the ST segment in the electrocardiogram (p < 0·001) and coming to the ED [14,23]. short reinforcement training sessions being run for emergency With respect to the clinical variables in the results, our study nurses (p = 0·028) (Table 3). confirms that delays in the diagnosis have an impact on mortal- ity [21,24]. Intra-hospital cardiac mortality is higher than in other studies in a stage in which AMI treatment was already organized Discussion by MI code networks [25]. However, it should be noted that 11·4% of the population included in the study were patients whose first The following aspects have been determined in our observa- event was cardiorespiratory arrest, and there is evidence of high tions: 1) The STEMI patients with the longest delays are mostly mortality among this group of patients [23]. women and the elderly. 2) These patients with the longest delay also present higher mortality and longer hospital stays. 3) The 144 G. Berga Congost et al. Australasian Emergency Care 24 (2021) 141–146 Table 2 Main variable and response times in acute myocardial infarction. The figures show n (%) Median (interquartile range). Time intervals: minutes (min). ECG: electrocardiogram. ED: Emergency Department. FMC: first medical contact. Hemo: haemodynamic. Time Variables Total STEMI CODE ER/Balloon ≤70 min ER/Balloon >70 min p FMC/ECG ≤ 10 min FMC/ECG > 10 min p Number of patients 327 (100) 80(24·46) 166(50·76) 167(51·07) 160(48·93) Pain/ FMC 80(25–180) 60(25–120) 101(30–244) 0·019 65(25–141) 102(24–265) 0·032 FMC/ ECG 10(5–26) 6(4–17) 12(7–31) <0·001 5(4–8) 27(15–59) 0·001 ECG/ Activation 30(12–75) 12(5–33) 35(15–99) <0·001 25(10–56) 33(15–95) 0·007 ED/Balloon 88(65–121) 55(47–64) 108(86–161) <0·001 78(59–110) 97(75–158) <0·001 Activation/Hemo 30(20–35) 21(14–31) 30(25–37) <0·001 30(17–36) 30(20–35) 0·752 Hemo/Balloon 25(20–31) 22(18–25) 27(22–35) <0·001 25(20–29) 26(20–33) 0·191 FMC/Balloon 109(77–160) 67(55–100) 129(95–195) <0·001 90(65–125) 131(97–215) <0·001 Pain/Balloon 207(135–400) 142(95–203) 256(171–495) <0·001 185(118–265) 265(155–536) <0·001 ECG/Balloon 88(65–132) 61 (49–84) 100 (77–164) <0·001 87 (66–156) 90 (61–120) 0·059 Table 3 Predictive factors of delay in D2B for STEMI patients. CI: confidence interval. ECG: electrocardiogram. Variables HR 95% CI p-value Gender 0.061 (−24.208 to 69.426) 0.342 Age 0.083 (−0.483 to 2.363) 0.194 Working hours −0.102 (−71.693 to 6.082) 0.098 Chest pain −0.069 (−76.686 to 21.352) 0.267 ECG with ST elevation −0.258 (−157.037 to −57.103) <0.001 Nurse training sessions −0.135 (−107.141 to −6.263) 0.028 The results obtained with respect to increased hospital stay in data is taken from the Codi IAM register increase the reliability of the delayed group, as well as in terms of false positives, are in the results, as it can be audited and is consistent with other data concordance with the studies in the literature [26]. reported. As seen in other reported series, when analysing the times In conclusion, response times in cases of myocardial infarction obtained, significant delays and low adherence to the STEMI quality are subject to delays, particularly in specific groups of patients indicators were observed [7,14,24]. These records focus on the D2B that require special supervision. The measures incorporated using time because it is considered to be an optimal indicator of the hos- the Plan-Do-Check-Act methodology provide specific interventions pital’s healthcare quality and the degree of alignment with the PPCI throughout the process that guarantee continuous improvement, program [11]. In contrast to other studies, the non-delayed treat- increasing the safety and quality of the process. Moreover, regu- ment group was defined with a D2B ≤ 70 min [21,23,24]. Moreover, lar audits should be conducted to quantify and compare healthcare in our study, the time between arrival at the ED and electrocardio- quality, delays and clinical results, in order to improve these param- gram is adequate, particularly when the patient has not had any eters. Hospitals and healthcare networks should allocate time and medical contact before coming to the ED, and differs from other resources to measuring their results and developing continuous studies insofar as the haemodynamic-balloon interval is not subject improvement strategies to achieve optimal performance. to delays attributable to technical difficulties in the PCI [28]. It should be highlighted that, in the case of the pain/FMC interval Funding and even the pain/balloon intervals, the delay is more dependent on the patient themselves. Therefore, education and awareness cam- The Government of Catalonia (Spain) provided funding for this paigns should be run among the population [27]. The rest of the research, with a grant issued in 2019 within the framework of the intervals recorded correspond to system delays. It is in relation Strategic Health Research and Innovation Plan (PERIS) 2016-2020, to these intervals that a clear Plan-Do-Check-Act strategy must be with the file code SLT008/18/00052. established, with measures adapted to resolve them. The findings of our research confirm that short reinforcement Role of the funding source training sessions on MI for emergency nurses lead to an improve- ment in delays in the D2B, generating improved diagnosis and The funders of the study played no role in study design, data col- treatment [21]. Despite evidence on the efficacy of organizational lection, data analysis, data interpretation, or writing of the report. variables with respect to reducing MI response times, few authors The corresponding author had full access to all the data in the include these variables in their evaluation of delays [29,30]. It study and had final responsibility for the decision to submit for should be noted that the studies that do incorporate these variables publication. in their records analyse the delays in a fragmented way, without establishing an overall continuous improvement methodology for Declaration of conflicts of interest healthcare quality. In contrast, our study is focused towards this purpose. The research results confirm that implementing differ- The authors have no conflicts of interest to declare. ent organizational strategies aligned with the Plan-Do-Check-Act model leads to a reduction in delays in the system. Running short Acknowledgements training sessions on AMI for emergency nurses appears to con- tribute towards improving delays in D2B. We thank all participants, health centre staff. The Government The main limitations of this study are the sample size, which of Catalonia (Spain), Department of Health, provided funding for is retrospective and taken from a single hospital. 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