Emergency. 2018; 6 (1): e14

LE T T E R TO ED I TO R

Key Performance Indicators of Chest Pain Management in
Emergency Department; a Letter to the Editor
Mehrdad Taghizadeh1, Roghayeh Taghipour1∗, Kamran Heydari1

1. Emergency Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Received: January 2018; Accepted: February 2018; Published online: 18 February 2018

Cite this article as: Key Performance Indicators of Chest Pain Management in Emergency Department; a Letter to the Editor. Emergency.

2018; 6(1): e14.

Dear editor:
Chest pain is a common complaint among those presenting

to emergency department (ED) and is associated with a

high rate of mortality. Based on National Center for Health

Statistics, chest pain leads to about 6 million visits to EDs

in United State. In Iran, ischemic cardiac diseases are the

second cause of death in people aged 15 to 49 years (1).

While less than 10% of the patients presenting to ED with

chest pain are affected with myocardial infarction (MI),

33% of MI cases are silent (2). Timely diagnosis and re-

vascularization of ischemic part, using thrombolytic agents

or percutaneous coronary intervention (PCI), can save car-

diac function and the patient’s life (3).

Therefore, in this regard the emphasis is on rapid referral

of the patients to treatment centers, initiation of diagnostic

measures such as electrocardiography (ECG) and in case

of meeting the required criteria, transfer to cat lab for

PCI. American Heart Association (AHA) has introduced the

proper door to ECG time as 10 minutes if it has not been done

in the ambulance (4). Based on this recommendation, AHA

has defined the aims of coronary reperfusion as prescription

of thrombolytic in the initial 30 minutes after admission

of the patient to ED or PCI in the initial 90 minutes after

admission to ED.

Efficacy of reperfusion therapy decreases with an increase

in the time interval between manifestation of symptoms

and initiation of treatment. Potential delay in initiation of

reperfusion therapy can be due to increase in Door to Data,

Data to Decision, and Decision to Drug times. Therefore,

improvement of these times as a series of Key Performance

Indicators has always been of interest to health care man-

agers. By performing a clinical audit on 781 patients with the

∗Corresponding Author: Roghayeh Taghipour; Emergency Department,
Loghman Hakim Hospital, Makhsous Street, Lashgar Junction, Tehran, Iran.
Tel: +989121370265 Email: rota425@gmail.com

mean age of 50.91 ± 16.76 (20 -93) years who were included
via non-probability census sampling and had presented to

ED of Loghman Hakim Hospital, Tehran, Iran, during 1.5

years with the chief complaint of chest pain (53.3% male),

the writers of the present letter estimated mean and standard

deviation of door to first ECG performance time as 22.47 ±
16.59 (0 – 94) minutes. Time interval between admission of

the patient to receiving thrombolytic in this study was 46.60

± 17.98 (22–82).
Mean and standard deviation of the time interval between

ECG to making a decision for starting thrombolytic, for 23

patients with ST segment elevation myocardial infarction

(STEMI), was 26.90 ± 18.15 (0 – 65) minutes. In addition
decision time to injection of thrombolytic in this study was

almost 0 since decision making was done in ED while the

drug was present at the patient’s bedside.

There was no significant difference between various working

shifts including morning (22.62 ± 16.01 minutes), evening
(22.15 ± 16.61 minutes), and night (22.24 ± 17.33 minutes)
in this regard (p = 0.827). The final diagnosis was unstable

angina for 151 (19.3%) cases, MI in 32 (4.1%) cases (23 STEMI

cases), and pulmonary embolism in 2 (0.3%) cases.

As can be seen, door to first ECG time in the studied ED is

approximately twice the standard time proposed by AHA. In

addition, door to drug time interval is also about 1.5 times

more than the mentioned standard.

Managers of the mentioned ED attempted to relieve the

problem by increasing the number of ECG devices and

putting someone in charge of performing ECG for each

shift. In addition, by training triage nurses it was decided

that all the patients presenting to ED with complaint of

non-traumatic chest pain, either typical or atypical, should

undergo screening immediately using ECG in the fast track

and their ECG should be interpreted by the senior resident

in each shift. Additionally, the method of recording the

mentioned times was changed from manual, which was

estimated and recorded with 3 to 5 minutes delay from the

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M. Taghizadeh et al. 2

time of initiation of the measures by a nurse, to automatic

with calibrated ECG devices.

Overall, it seems that improvement of the mentioned times

needs constant care of the ED managers and continuous

training of triage and EMS personnel for acceleration of

providing diagnostic and treatment services to these pa-

tients. It should be noted that fortunately by setting up “724

system” by the ministry of health and performance of ECG

in the ambulance and transmitting the data from the ambu-

lance to the dispatch center, this problem will be solved soon.

1. Appendix

1.1. Acknowledgements

The personnel of Loghman Hakim Hospital Emergency De-

partment are thanked for their cooperation in performing the

present research project.

1.2. Author contribution

All the authors meet the standard criteria of authorship based

on the recommendations of the international committee of

medical journal editors.

1.3. Funding/Support

No financial support has been received.

1.4. Conflict of interest

There is none.

References

1. Forouzanfar MH, Sepanlou SG, Shahraz S, BESc PN, Pour-

malek F, Lozano R, et al. Evaluating causes of death and

morbidity in Iran, global burden of diseases, injuries,

and risk factors study 2010. Archives of Iranian medicine.

2014;17(5):304.

2. Canto JG, Shlipak MG, Rogers WJ, Malmgren JA, Frederick

PD, Lambrew CT, et al. Prevalence, clinical characteristics,

and mortality among patients with myocardial infarction

presenting without chest pain. Jama. 2000;283(24):3223-9.

3. Roe MT, Messenger JC, Weintraub WS, Cannon CP,

Fonarow GC, Dai D, et al. Treatments, trends, and out-

comes of acute myocardial infarction and percutaneous

coronary intervention. Journal of the American College of

Cardiology. 2010;56(4):254-63.

4. O’Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung

MK, De Lemos JA, et al. 2013 ACCF/AHA guideline for

the management of ST-elevation myocardial infarction:

a report of the American College of Cardiology Founda-

tion/American Heart Association Task Force on Practice

Guidelines. Journal of the American College of Cardiology.

2013;61(4):e78-e140.

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	Appendix
	References