Improving time-sensitive processes in the intensive care unit: the exampleof 'door-to-needle time' in acute myocardial infarction

Objective. To assess and reduce delays in coronary thrombolysis in patients with acute myocardial infarction. Design. Prospective, descriptive study using statistical process control. Setting. Interdisciplinary intensive care unit of a 300-bed community hospi tal. Subjects. Thirty-seven consecutive patients with acute myocardial infarctio n who were receiving thrombolytic therapy. Interventions. To perform an interdisciplinary formal process analysis aime d;it detecting delay-causing factors, review of existing house rules, gener ation and implementation of new practice guidelines Main outcome measures. Comparison of 'door-to-needle times' of patients adm itted before, during and after formal process analysis and implementation o f new guidelines. Results. Mean 'door-to-needle time' fell significantly from 57 minutes (+/- 25.4) in 16 patients studied before, to 32 minutes (+/-9.0) in 16 patients studied after the formal process analysis and the implementation of new gu idelines (P < 0.002). An even more pronounced but transient decrease to 24 minutes (+/- 3.8) was observed in five patients studied during the phase of formal process analysis (P < 0.004). Delay-causing factors were identified in the areas 'communication', 'people' and 'methods/rules/guidelines'. Equ ipment failure was never responsible for delays. Conclusions. Formal process analysis, followed by implementation of revised guidelines resulted in a significant reduction of 'door-to-needle time'. A n initial dramatic but transient reduction of 'door-to-needle time' was con sidered observational and must not be mistaken as the definite new level of performance. We conclude that formal process analysis techniques are suite d to improve processes in the intensive care unit.