Skip to main content
NCBI home page
Emergency Medicine Journal : EMJ logoLink to Emergency Medicine Journal : EMJ
. 2004 Nov;21(6):676–680. doi: 10.1136/emj.2004.014449

Emergency department thrombolysis improves door to needle times

A Corfield 1, C Graham 1, J Adams 1, I Booth 1, A McGuffie 1
PMCID: PMC1726488  PMID: 15496692

Abstract

Objective: To identify the effect on door to needle (DTN) time of moving the site of thrombolysis delivery from the coronary care unit (CCU) to the emergency department (ED). To ascertain if moving the site of thrombolysis enables appropriate use of thrombolysis.

Design: Prospective cohort study.

Setting: CCU and ED of a 450 bed Scottish district general hospital without on-site primary angioplasty.

Participants: Primary site for thrombolysis of patients presenting to the hospital with ST elevation MI (STEMI) moved from CCU to ED on 1 April 2000. Study patients who had a confirmed STEMI and/or received thrombolytic therapy before this date were defined as the pre-change group; those who were diagnosed as STEMI and/or received thrombolytic therapy after this date were defined as the post-change group.

Statistical analysis: Mann-Whitney test was used to compare medians and χ2 test for categorical data.

Results: 1349 patients were discharged from CCU with a diagnosis of STEMI or received thrombolysis in the ED or CCU between April 1998 and April 2002. There were 632 patients in the pre-change group and 654 patients in the post-change group. Sixty three patients were excluded. Median DTN time for the pre-change group (321 thrombolysed patients) was 64 minutes and median DTN time for the post-change group (324 thrombolysed patients) was 35 minutes, a median difference of 25 minutes (95% CI for difference 20 to 29 minutes, p<0.0001, Mann-Whitney U test). A total of 37 patients were thrombolysed but did not have a final diagnosis of STEMI.

Conclusion: A significant reduction in DTN times accompanied this change in practice in this hospital.

Full Text

The Full Text of this article is available as a PDF (69.6 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Andersen Henning R., Nielsen Torsten T., Rasmussen Klaus, Thuesen Leif, Kelbaek Henning, Thayssen Per, Abildgaard Ulrik, Pedersen Flemming, Madsen Jan K., Grande Peer. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med. 2003 Aug 21;349(8):733–742. doi: 10.1056/NEJMoa025142. [DOI] [PubMed] [Google Scholar]
  2. Birkhead J. S. Time delays in provision of thrombolytic treatment in six district hospitals. Joint Audit Committee of the British Cardiac Society and a Cardiology Committee of Royal College of Physicians of London. BMJ. 1992 Aug 22;305(6851):445–448. doi: 10.1136/bmj.305.6851.445. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Boersma E., Maas A. C., Deckers J. W., Simoons M. L. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet. 1996 Sep 21;348(9030):771–775. doi: 10.1016/S0140-6736(96)02514-7. [DOI] [PubMed] [Google Scholar]
  4. Boisjolie C. R., Sharkey S. W., Cannon C. P., Brunette D., Haugland J. M., Thatcher J. L., Henry T. D. Impact of a thrombolysis research trial on time to treatment for acute myocardial infarction in the emergency department. Am J Cardiol. 1995 Aug 15;76(5):396–398. doi: 10.1016/s0002-9149(99)80108-8. [DOI] [PubMed] [Google Scholar]
  5. Bryant M., Kelly A. M. "Point of entry" treatment gives best time to thrombolysis for acute myocardial infarction. Aust Health Rev. 2001;24(1):157–160. doi: 10.1071/ah010157. [DOI] [PubMed] [Google Scholar]
  6. Chan W. K., Lam K. N., Lau F. L., Tang H. M. Starting thrombolytic therapy for patients with acute myocardial infarction in Accident and Emergency Department: from implementation to evaluation. Chin Med J (Engl) 1998 Apr;111(4):291–294. [PubMed] [Google Scholar]
  7. De Belder M. A., Hall J. A. Infarct angioplasty. Heart. 1999 Oct;82(4):399–401. doi: 10.1136/hrt.82.4.399. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Edhouse J. A., Sakr M., Wardrope J., Morris F. P. Thrombolysis in acute myocardial infarction: the safety and efficiency of treatment in the accident and emergency department. J Accid Emerg Med. 1999 Sep;16(5):325–330. doi: 10.1136/emj.16.5.325. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Gonzalez E. R., Jones L. A., Ornato J. P., Bleecker G. C., Strauss M. J. Hospital delays and problems with thrombolytic administration in patients receiving thrombolytic therapy: a multicenter prospective assessment. Virginia Thrombolytic Study Group. Ann Emerg Med. 1992 Oct;21(10):1215–1221. doi: 10.1016/s0196-0644(05)81749-4. [DOI] [PubMed] [Google Scholar]
  10. Hourigan C. T., Mountain D., Langton P. E., Jacobs I. G., Rogers I. R., Jelinek G. A., Thompson P. L. Changing the site of delivery of thrombolytic treatment for acute myocardial infarction from the coronary care unit to the emergency department greatly reduces door to needle time. Heart. 2000 Aug;84(2):157–163. doi: 10.1136/heart.84.2.157. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Jacobs Alice K. Primary angioplasty for acute myocardial infarction--is it worth the wait? N Engl J Med. 2003 Aug 21;349(8):798–800. doi: 10.1056/NEJMe038116. [DOI] [PubMed] [Google Scholar]
  12. Koren G., Weiss A. T., Hasin Y., Appelbaum D., Welber S., Rozenman Y., Lotan C., Mosseri M., Sapoznikov D., Luria M. H. Prevention of myocardial damage in acute myocardial ischemia by early treatment with intravenous streptokinase. N Engl J Med. 1985 Nov 28;313(22):1384–1389. doi: 10.1056/NEJM198511283132204. [DOI] [PubMed] [Google Scholar]
  13. Lau J., Antman E. M., Jimenez-Silva J., Kupelnick B., Mosteller F., Chalmers T. C. Cumulative meta-analysis of therapeutic trials for myocardial infarction. N Engl J Med. 1992 Jul 23;327(4):248–254. doi: 10.1056/NEJM199207233270406. [DOI] [PubMed] [Google Scholar]
  14. Newby L. K., Rutsch W. R., Califf R. M., Simoons M. L., Aylward P. E., Armstrong P. W., Woodlief L. H., Lee K. L., Topol E. J., Van de Werf F. Time from symptom onset to treatment and outcomes after thrombolytic therapy. GUSTO-1 Investigators. J Am Coll Cardiol. 1996 Jun;27(7):1646–1655. doi: 10.1016/0735-1097(96)00053-8. [DOI] [PubMed] [Google Scholar]
  15. Pedley David K., Bissett Kim, Connolly Elizabeth M., Goodman Carol G., Golding Ian, Pringle T. H., McNeill G. P., Pringle S. D., Jones M. C. Prospective observational cohort study of time saved by prehospital thrombolysis for ST elevation myocardial infarction delivered by paramedics. BMJ. 2003 Jul 5;327(7405):22–26. doi: 10.1136/bmj.327.7405.22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Pell A. C., Miller H. C., Robertson C. E., Fox K. A. Effect of "fast track" admission for acute myocardial infarction on delay to thrombolysis. BMJ. 1992 Jan 11;304(6819):83–87. doi: 10.1136/bmj.304.6819.83. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Prasad N., Wright A., Hogg K. J., Dunn F. G. Direct admission to the coronary care unit by the ambulance service for patients with suspected myocardial infarction. Heart. 1997 Nov;78(5):462–464. doi: 10.1136/hrt.78.5.462. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Qasim Asif, Malpass Kerry, O'Gorman Daniel J., Heber Mary E. Safety and efficacy of nurse initiated thrombolysis in patients with acute myocardial infarction. BMJ. 2002 Jun 1;324(7349):1328–1331. doi: 10.1136/bmj.324.7349.1328. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Sandler D. A. Paramedic direct admission of heart-attack patients to a coronary-care unit. Lancet. 1998 Oct 10;352(9135):1198–1198. doi: 10.1016/S0140-6736(05)60536-3. [DOI] [PubMed] [Google Scholar]
  20. Selker H. P., Griffith J. L., Beshansky J. R., Schmid C. H., Califf R. M., D'Agostino R. B., Laks M. M., Lee K. L., Maynard C., Selvester R. H. Patient-specific predictions of outcomes in myocardial infarction for real-time emergency use: a thrombolytic predictive instrument. Ann Intern Med. 1997 Oct 1;127(7):538–556. doi: 10.7326/0003-4819-127-7-199710010-00006. [DOI] [PubMed] [Google Scholar]
  21. Sharkey S. W., Bruneete D. D., Ruiz E., Hession W. T., Wysham D. G., Goldenberg I. F., Hodges M. An analysis of time delays preceding thrombolysis for acute myocardial infarction. JAMA. 1989 Dec 8;262(22):3171–3174. [PubMed] [Google Scholar]
  22. Somauroo J. D., McCarten P., Appleton B., Amadi A., Rodrigues E. Effectiveness of a 'thrombolysis nurse' in shortening delay to thrombolysis in acute myocardial infarction. J R Coll Physicians Lond. 1999 Jan-Feb;33(1):46–50. [PMC free article] [PubMed] [Google Scholar]
  23. Topol E. J., Ohman E. M., Armstrong P. W., Wilcox R., Skene A. M., Aylward P., Simes J., Dalby A., Betriu A., Bode C. Survival outcomes 1 year after reperfusion therapy with either alteplase or reteplase for acute myocardial infarction: results from the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) III Trial. Circulation. 2000 Oct 10;102(15):1761–1765. doi: 10.1161/01.cir.102.15.1761. [DOI] [PubMed] [Google Scholar]
  24. Tunstall-Pedoe H., Kuulasmaa K., Amouyel P., Arveiler D., Rajakangas A. M., Pajak A. Myocardial infarction and coronary deaths in the World Health Organization MONICA Project. Registration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents. Circulation. 1994 Jul;90(1):583–612. doi: 10.1161/01.cir.90.1.583. [DOI] [PubMed] [Google Scholar]
  25. Wilmshurst P., Purchase A., Webb C., Jowett C., Quinn T. Improving door to needle times with nurse initiated thrombolysis. Heart. 2000 Sep;84(3):262–266. doi: 10.1136/heart.84.3.262. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Emergency Medicine Journal : EMJ are provided here courtesy of BMJ Publishing Group

RESOURCES