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Canadian Journal of Cardiology

IMPACT OF EMERGENCY DEPARTMENT TRIAGE ON TIMELY ECG ACQUISITION

      BACKGROUND

      Percutaneous coronary intervention (PCI) is the standard of care reperfusion therapy in the management of STEMI. Timeliness is critical to the effectiveness of PCI and shorter times to reperfusion are associated with decreased morbidity and mortality. To expedite reperfusion, guidelines recommend STEMI patients should receive an ECG within 10 minutes from initial presentation, represented as first medical contact to electrocardiogram (FMC-to-ECG) time. Various factors have been suggested to impact FMC-to-ECG time including triaged acuity, measured by the Canadian Triage and Acuity Scale (CTAS). Designations of CTAS 1 and 2 indicate higher triage levels demanding priority attention over CTAS 3, 4 or 5.

      METHODS AND RESULTS

      This is a retrospective observational study of three emergency departments (ED) within a non-PCI capable health system. Walk-in patients with an ECG suggesting STEMI from 2017-2019 were identified (n=276). Charts were reviewed and only true walk-in patients with a final diagnosis of STEMI and data necessary to calculate FMC-to-ECG times were included (n=165). Furthermore, all patients with a chief complaint of chest pain presenting to the three emergency departments during 2017-2019 were also identified to establish a baseline CTAS triage rate. The primary objective of this study is to investigate if ED triage acuity is associated with timely ECG in walk-in STEMI patients. 95% of STEMI patients were triaged as CTAS 1 or 2 compared to 79.7% of all patients presenting with a complaint of chest pain. 55% of STEMI patients with a CTAS 1 or 2 designation received a timely ECG compared to 50% of STEMI patients with a CTAS 3, 4 or 5 designation. Statistical analysis of proportions between groups was performed by using Chi squared tests of independence or Fisher's exact test where appropriate.

      CONCLUSION

      Walk-in STEMI patients were significantly more likely to receive a higher priority CTAS designation of 1 or 2 compared with any patient presenting with chest pain. Despite the appropriate triage designation, only 55% of CTAS 1 or 2 patients received timely ECGs and they were not more likely to receive a timely ECG over lower priority CTAS designations. Taken together, these findings suggest the presence of a system-related delay in FMC-to-ECG time. Interventions designed to improve the ability of patients to receive ECGs and activate STEMI management pathways at the level of ED triage may be helpful in identifying STEMI patients earlier, thereby expediting their reperfusion time.
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