Door to needle times of 12 minutes are possible in one emergency department

Editor—Several correspondents have discussed call to needle times after acute myocardial infarction.¹ Rapid door to needle times are possible in accident and emergency departments with the use of appropriate protocols and the availability of cover by senior medical staff on the floor 24 hours a day.

In the emergency department of this hospital all adult patients with chest pain are taken immediately to a cubicle by nursing staff; before they see a doctor oxygen treatment and electrocardiographic monitoring are started and an intravenous line is inserted. A 12 lead electrocardiogram is taken to the attending emergency doctor even before it is labelled. When an acute myocardial infarction is diagnosable from this first electrocardiogram the door to needle times are around 12 minutes. Thus thrombolysis is routinely administered in this emergency department.

The key points are that the nurses do not require medical authorisation to instigate their protocol and that the first doctor to read the electrocardiogram has the competence to interpret it correctly and the authority to instigate thrombolysis.

This hospital has a tertiary cardiac surgical service, and its cardiologists envisaged from the outset that the emergency department would function in this way.