Impact of a Screening Protocol on Door to Ecg Time in the Accident and Emergency Department of Kenyatta National Hospital

Abstract

Cardiovascular disease constitutes a major increasing disease burden in the developing world. Kenyatta National Hospital does not have a specific chest pain protocol despite Acute Coronary Syndrome (ACS) being a true medical emergency requiring prompt diagnosis and immediate management. The American College of cardiology/American Heart Association (ACC/AHA) recommends that patients presenting with suspected ACS should have an Electrocardiogram (ECG) within 10 minutes of first medical contact. This has a direct impact on the subsequent diagnosis and definitive management. Objectives To determine the current triage practice, implement a screening protocol and evaluate its impact on door to ECG time of patients with suspected Acute Coronary Syndrome presenting at the Accident and Emergency (A&E) Department in Kenyatta National Hospital (KNH). Specific objectives 1. To determine the proportion of patients at high risk for acute coronary syndrome who obtain an ECG at the Accidents and Emergency department of KNH. 2. To determine the door to ECG time of patients at high risk for ACS at the A&E department. 3. To evaluate the impact of a screening protocol implemented at the triage station on the proportion and on the Door to ECG time of patients at high risk for ACS at the A&E department Methods This was a quasi-experimental study in which assessment of door to ECG time before and after implementation of a triage screening protocol. The intervention involved provision of a simple ECG prioritization tool and free ECG service administered to non- surgical patients aged >30 years prior to doctors’ consultation. Analysis Door to ECG time was dichotomized to early <10 minutes verses delayed >10 minutes and presented as percentages with 95% confidence interval. Univariate analysis was done to compare the proportions of patients receiving ECG and of those receiving an early or delayed ECG before and after intervention using the McNemar test. Comparisons of the mean time to ECG before and after the intervention was done using Wilcoxon signed rank sum test. A p value of <0.05 was considered significant. Results. It was found that 14.4% (95% CI 10.06 – 20.09) of patients with a high probability of Acute coronary syndrome had an ECG done with a mean door to ECG time of 10.2hrs (SD 7.18) median of 8.08hrs (IQR 4.65-13.1). None obtained an ECG within the recommended 10 minutes. Post intervention, 93.6% of patients had an ECG done with a mean door to ECG time of 2.5hrs (SD4.02), Median 69minutes IQR (20-163). 9.4% of patients obtained the ECG within 10 minutes and patients were 86.7 times more likely to receive an ECG post intervention p < 0.05. Conclusion The current screening and diagnosis of suspected ACS is sub-optimal. The institution of an ECG triage tool and free ECG service can significantly bridge this gap.