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A Method for Improving Arrival-to- electrocardiogram Time in ...
CLINICAL INVESTIGATION A Method for Improving Arrival-to- electrocardiogram Time in Emergency Department Chest Pain Patients and the Effect on Door-to-balloon Time for ST-segment Elevation Myocardial Infarction Kevin M. Takakuwa, MD, Gregory A. Burek, Adrian T. Estepa, and Frances S. Shofer, PhD Abstract Objectives: The objectives were to determine if an emergency department (ED) could improve the adherence to a door-to-electrocardiogram (ECG) time goal of 10 minutes or less for patients who presented to an ED with chest pain and the effect of this adherence on door-to-balloon (DTB) time for ST-segment elevation myocardial infarction (STEMI) cardiac catheterization (cath) alert patients. Methods: This was a planned 1-month before-and-after interventional study design for implementing a new process for obtaining ECGs in patients presenting to the study ED with chest pain. Prior to the change, patients were registered and triaged before an ECG was obtained. The new procedure required registration clerks to identify those with chest pain and directly overhead page or call a designated ECG technician. This technician had other ED duties, but prioritized performing ECGs and delivering them to attending physicians. A full registration process occurred after the clinical staff performed their initial assessment. The primary outcome was the total percentage of patients with chest pain who received an ECG within 10 minutes of ED arrival. The secondary outcome was DTB time for patients with STEMI who were emergently cath alerted. Data were analyzed using mean differences, 95% conﬁdence intervals (CIs), and relative risk (RR) regression to adjust for possible confounders. Results: A total of 719 patients were studied: 313 before and 405 after the intervention. The mean (±standard deviation [SD]) age was 50 (±16) years, 54% were women, 57% were African American, and 36% were white. Patients walked in 89% of the time; 11% arrived by ambulance. Thirty-nine percent were triaged as emergent and 61% as nonemergent. Patients presented during daytime 68% of the time, and 32% presented during the night. Before the intervention, 16% received an ECG at 10 minutes or less. After the intervention, 64% met the time requirement, for a mean difference of 47.3% (95% CI = 40.8% to 53.3%, p < 0.0001). Results were not affected by age, sex, race, mode of arrival, triage clas- siﬁcation, or time of arrival. For patients with STEMI cath alerts, four were seen before and seven after the intervention. No patients before the intervention had ECG time within 10 minutes, and one of four had DTB time of <90 minutes. After the intervention, all seven patients had ECG time within 10 minutes; the three arriving during weekday hours when the cath team was on site had DTB times of <90 minutes, but the four arriving at night and on weekends when the cath team was off site had DTB times of >90 minutes. Conclusions: The overall percentage of patients with a door-to-ECG time within 10 minutes improved without increasing stafﬁng. An ECG was performed within 10 minutes of arrival for all patients who were STEMI cath alerted, but DTB time under 90 minutes was achieved only when the cath team was on site. ACADEMIC EMERGENCY MEDICINE 2009; 16:921–927 ª 2009 by the Society for Academic Emergency Medicine Keywords: chest pain, electrocardiogram, ECG, door-to-ECG time, door-to-balloon time From the Department of Emergency Medicine, Thomas Jefferson University Hospital (KMT, GAB, ATE); and the Department of Emergency Medicine, University of Pennsylvania Health System (FSS), Philadelphia, PA. Received January 27, 2009; revisions received April 22, May 1, and May 4, 2009; accepted May 10, 2009. Presented at the 12th International Conference on Emergency Medicine, San Francisco, CA, April 3, 2008. Address for reprints or correspondence: Kevin M. Takakuwa, MD; e-mail: Kevin.Takakuwa@jefferson.edu. ª 2009 by the Society for Academic Emergency Medicine ISSN 1069-6563 doi: 10.1111/j.1553-2712.2009.00493.x PII ISSN 1069-6563583 921 Copyright Agency Limited (CAL) licenced copy 922 Takakuwa et al. • ECG TIME T he guidelines of the American College of Cardiol- Study Setting and Population ogy and the American Heart Association This study was conducted at Thomas Jefferson Univer- (ACC ⁄ AHA) specify that a 12-lead electrocardio- sity Hospital, an urban Level 1 trauma center and ter- gram (ECG) should be obtained and interpreted as soon tiary care hospital with an ED that has an annual as possible after a patient arrives to an emergency census of more than 60,000 visits. All patients aged department (ED) with chest discomfort or symptoms sus- 18 years and older who presented to our ED between picious for acute coronary syndrome (ACS).1,2 They September 1, 2007, and October 31, 2007, with any specify a time goal of within 10 minutes of arrival, which mention or complaint of chest pain were included. may be an optimistic goal. In contrast, the Veterans Health Administration measures the percentage of Study Protocol patients with cardiac symptoms who undergo an ECG In 2007, facing prolonged ECG and DTB times, our within 10 minutes and do not measure the duration of hospital’s Chest Pain Center Committee, a working the extra step of ECG interpretation.3 The ACC ⁄ AHA group composed of the leaders of emergency medi- further recommends that patients with ST-segment ele- cine, interventional cardiology, the cardiac care unit, vation myocardial infarction (STEMI) receive percutane- ED and hospital nursing, and hospital administrators, ous coronary intervention (PCI) in 90 minutes or less.4 recognized the importance of improving door-to-ECG A study reporting on 63,478 high-risk non-ST-seg- times to within 10 minutes as a way to improve DTB ment elevation ACS patients revealed that only 33% had time, with a DTB goal of 90 minutes or less. We began ECGs in less than 10 minutes of arrival; the median tracking the time to ECG for all patients who com- ECG time was 15 minutes.5 Another study of 8,885 ED plained of chest pain during registration or triage visits showed that 34% of non-ST-elevation ACS and early in 2007. We had already been tracking DTB time 40.9% of STEMI patients had an ECG within 10 minutes for all emergency cath alerts for years prior to the of arrival.6 The study further demonstrated an increased new intervention. A cath alert in our hospital occurs risk of adverse clinical outcomes for STEMI patients when an ED patient presents with a STEMI or new who had ECGs greater than 10 minutes after arrival. A left bundle branch block (LBBB) that triggers a rapid study of undifferentiated chest pain patients showed response to move the patient to our cardiac cath labo- that whites received ECGs faster than nonwhites, and ratory for PCI. men received ECGs faster than women, although these differences disappeared for ACS patients.7 Before Intervention. During this time, when a patient The beneﬁt of a rapid initial ECG is intuitive for a came to our ED, he or she would be directed to a regis- number of reasons. First, the ECG results direct subse- tration desk for a brief registration process that quent care down different pathways. Logically, ECG included name, date of birth, and chief complaint. If the delays can lengthen time to other therapies such as patient mentioned chest pain, the registration clerk thrombolysis and cardiac catheterization (cath). ECG would send the patient to triage. The triage nurse changes (ST-segment elevation and new Q waves) would then assess the patient and order an ECG if ACS increase the likelihood of ACS, while normal ECG was suspected. The ECG would be taken by any avail- results decrease the chances of ACS.8 The National able technician and could be delayed if the technician Heart Attack Alert Program Coordinating Committee decided to insert an intravenous line, draw up blood has made suggestions for improving ECG time, includ- tests, and deliver the blood to the nurse assigned to the ing standing orders to perform ECGs, housing ECG patient. The technician was responsible for delivering machines in EDs, and having ECG technicians available the ECG to an attending physician for interpretation, within 5 minutes of paging.9 However, neither they nor and those ECGs were logged into a separate database the ACC ⁄ AHA provide speciﬁc recommendations on that was accessible to the Chest Pain Center Commit- how to implement adherence to a 10-minute goal, if it tee. It was this method that comprised the preinterven- is even possible. tional group of patients. The primary purpose of our study was to determine if we could improve adherence to our door-to-ECG After Intervention. Nursing, ED technicians, and time goal of 10 minutes or less for patients who pre- registration staff devised a plan to improve door-to- sented to our ED with chest pain by implementing a ECG time without the need for an increase in stafﬁng. new process for obtaining ECGs, without increasing No other interventions were scheduled or implemented stafﬁng. The secondary goal was to describe how the during the time period. All nonclinical staff members in new process affected the door-to-balloon (DTB) time the ED waiting room would direct patients to the regis- for STEMI cath alert patients. tration desk. The registration clerks were trained to ask patients for their chief complaint. If a patient com- METHODS plained of chest pain or afﬁrmed chest pain after being prompted for complaints that were not trauma-related Study Design but could be ACS-related (e.g., symptoms such as This was a planned before-and-after interventional weakness, shortness of breath, or epigastric pain), a study design of ED arrival-to-ECG time. We tested the quick registration would be taken that comprised name null hypothesis that we could not improve the percent- and date of birth. Next, the registration staff would age of patients who received an ECG within 10 min- immediately overhead page or directly call a designated utes. The study was approved by our institutional ECG technician to the triage station. review board. Copyright Agency Limited (CAL) licenced copy ACAD EMERG MED • October 2009, Vol. 16, No. 10 • www.aemj.org 923 At the start of every shift, one ED technician would Outcome Measures be assigned to carry the new ECG cell phone. That The primary outcome was the interval from ED arrival technician’s primary responsibility was performing time to ECG completion time. With a sample size of 300 ECGs and immediately delivering them to attending in each group, the study was powered to detect a mini- physicians, although the technician had other ED mum difference of 2 minutes between groups with duties. Emergency physicians were responsible for power set at 90% and alpha at 0.05. Arrival time was recording the time of ECG interpretation on a log taken from our computerized tracking system and using computerized time. A backup ECG technician began once the quick registration time was initiated, whose primary assignment was in the ED was also which we refer to as door time. ECG completion time identiﬁed who would be handed the cell phone by was taken from computerized ECG logs that were syn- the ED charge nurse when the primary ECG techni- chronized to our computerized tracking system. The cian was on a break or otherwise unavailable. He or difference between ECG completion time and comput- she also served as a second ECG technician during erized arrival time was calculated as door-to-ECG time. times of high patient volume, when a second triage The secondary outcome, DTB time, was taken as the and ECG area was used if a second chest pain pre- difference between the time of registration and the time sented. the coronary catheter guidewire passed the culprit After the ED technician veriﬁed with the ED attend- lesion as reported by the interventional cardiologist. ing that there was not a STEMI or new LBBB, he or she would return to the patient to draw blood. A Data Analysis triage nurse would then assess the patient and assign To determine whether patients differed before and after the acuity by our hospital’s modiﬁed Emergency intervention with regard to age, sex, race, triage classi- Severity Index (ESI) criteria.10 In our hospital, we ﬁcation (ESI 1–2, which we dichotomized to as ‘‘emer- assign as follows: 1 = immediate resuscitation, 2 = gent’’ vs. 3–4, which we refer to as ‘‘nonemergent’’), unstable vital signs ⁄ emergent, 3 = urgent, 4 = nonur- mode of arrival, and time of arrival, data were analyzed gent, and 5 = routine. Chest pain patients with a history using chi-square or Fisher’s exact tests. Door-to-ECG of coronary artery disease or an abnormal ECG are times are reported as medians ± interquartile ranges assigned as emergent, and those with no history of cor- (IQRs). For analysis purposes, these times were dichot- onary artery disease and a normal ECG are assigned as omized into £10 minutes or >10 minutes. Differences in urgent. Patients can also be assigned as nonurgent if the proportion of patients receiving ECG in £10 min- deemed to be very low risk for ACS at triage. No utes before and after the intervention were calculated patients included in this study were triaged as routine. with 95% conﬁdence intervals (CIs). To adjust for possi- A full registration by registration staff would occur ble confounders chosen a priori (age, sex, race, triage after the clinical nurse or physician performed his or classiﬁcation, mode of arrival, and time of arrival), rela- her initial assessment. tive risk (RR) regression using the Gaussian estimating For patients who arrived by ambulance, the process equation was performed.11,12 A post hoc analysis to remained unchanged due to geography and patient vol- examine door-to-ECG time and DTB time for STEMI ume. Patients who receive their ECG initiated from reg- alert patients was performed using the Wilcoxon rank istration have their ECG taken at the front of the sum test. All analyses were performed using SAS statis- department near registration. Patients who arrive via tical software (Version 9.1, SAS Institute, Cary, NC). A the ambulance bay enter through a door at the back of probability <0.05 was considered statistically signiﬁcant. the ED and are placed in a treatment room, triaged by the clinical nurse, and registered at the bedside. Because the primary ECG technician spent much time RESULTS performing ECGs on the walk-in patients, we had the A total of 718 consecutive patients with a complaint of nurse caring for the ambulance patient, or the ED tech- chest pain at triage were studied over 2 months: 313 nician assigned to that geographical area, do the ECG before and 405 after the intervention. The mean rather than take the ambulance stretcher to the front of (±standard deviation [SD]) age was 50 (±16) years; 54% the department when no registration information had were women, 57% were African American, 36% were been taken. white, and 7% were other races. Patients arrived on All data were retrospectively collected by trained their own (walked in) 89% of the time, and 11% research assistants and taken from our computerized arrived by ambulance. They were triaged as emergent tracking system in a preplanned analysis. We collected 39% of the time and nonemergent 61% of the time. data for 1 month before and 1 month after the imple- Patients presented during daytime hours 68% of the mentation of the new ECG process. There was no train- time and during night time hours 32% of the time. ing phase for this project. While the nursing and ECG Patients before and after the intervention were similar technicians were aware of the change, the ED physi- with regard to age, sex, race, mode of arrival, and cians were not. No staff members were notiﬁed that time of arrival (Table 1). Patients before the interven- ECG times were being formally analyzed for this study. tion were more likely to be classiﬁed as emergent Demographic information included age, sex, and race. (44% vs. 34%, difference = 10%, 95% CI = 3% to 17%, Other information collected included mode of arrival p = 0.007). (walk-in or ambulance), triage classiﬁcation (ESI), and Before the intervention, 16% of chest pain patients time of arrival (day time was deﬁned as 07:00–18:59, received ECGs at 10 minutes or less, and the median and night was 19:00–06:59). Copyright Agency Limited (CAL) licenced copy 924 Takakuwa et al. • ECG TIME Table 1 Variables Before and After the Intervention Variable Before, n (%) After, n (%) p-value Age, yr 50.5 ± 16.1 48.8 ± 16.5 0.17 Male sex 145 (46) 188 (46) 1.00 Race African American 185 (60) 224 (56) 0.47 White 106 (34) 156 (39) Other 17 (6) 21 (5) Triage classiﬁcation Emergent 139 (44) 138 (34) 0.007 Nonemergent 174 (56) 265 (66) Mode of arrival Walk-in 279 (89) 356 (88) 0.64 Ambulance 34 (11) 49 (12) Time of arrival Day (07:00–18:59) 212 (68) 273 (67) 0.94 Night (19:00–06:59) 101 (32) 132 (33) When examining time to ECG for walk-in versus ambulance patients, times signiﬁcantly improved after the intervention regardless of mode of arrival (Table 2). The largest improvement was for walk-in patients: 67% had an ECG performed within 10 minutes, compared to 15% before the intervention (difference = 52%, 95% CI = 46% to 58%). There were a total of 11 STEMI cath alerts during the study: four before (all were walk-in patients) and seven (four walk-ins) after the intervention (Table 3). There were no cath alerts for new LBBB. Prior to the inter- vention, none of the four patients had ECG time within 10 minutes. However, two of the STEMIs did not com- plain of chest pain: one patient’s chief complaint was dehydration, and the other was shortness of breath. The average DTB time for these four patients was 154 Figure 1. Time to ECG before and after intervention. (SD±72) minutes. Three of the four came during off- ECG = electrocardiogram. peak hours when the cath team had to be called into the hospital. All seven STEMI cath alerts that occurred after the door-to-ECG time was 16 minutes (IQR = 12–24). After intervention had ECG times within 10 minutes. All had the intervention, 64% of such patients met the time chest pain as their chief complaint, and the median time requirement of 10 minutes or less, and the median to ECG was 7 minutes (compared to 22 minutes in the door-to-ECG time was 9 minutes (IQR = 8–12 minutes). preintervention group, p < 0.05). The median DTB time The difference between the groups was 47.3% (95% for this group was 91 minutes (compared to 159 min- CI = 40.8% to 53.3%, p < 0.0001; Figure 1). After adjust- utes, p = NS). The three STEMI alerts that occurred ing for age, sex, race, mode of arrival, triage classiﬁca- during weekday hours when the cath team was on site tion, and time of arrival, patients after the intervention all had DTB times of <90 minutes, while the four STEMI were 3.9 times more likely to receive an ECG in 10 min- alerts that occurred during off peak hours had DTB utes or less (RR = 3.9, 95% CI = 3.0 to 5.1). times of >90 minutes. Table 2 Time to ECG Before and After Intervention for Walk-in Versus Ambulance Arrival Before Intervention After Intervention %<10 Min Time to ECG IQR %<10 Min Time to ECG IQR Difference 95% CI Walk-in 14.7 16 12–24 67.0 9 8–11 52.3% 46–58 Ambulance 17.7 17 12–26 38.3 12 12–18 20.6% 0.4–39 ECG = electrocardiogram; IQR = interquartile range. Copyright Agency Limited (CAL) licenced copy ACAD EMERG MED • October 2009, Vol. 16, No. 10 • www.aemj.org 925 Table 3 Pre- Versus Post-intervention STEMI Cath Alert Patients Arrival Time to DTB Age, yr Sex Race Chief Complaint ESI Mode ECG, min Time, min Time of Day Pre-intervention 49 Female White Chest pain 2 Walk-in 14 196 Weekday patients 53 Female White Chest pain 2 Walk-in 20 70 Night 45 Female African Shortness of 2 Walk-in 24 122 Weekday American breath 41 Male White Dehydration 3 Walk-in 56 229 Night Post-intervention 72 Male White Chest pain 2 Ambulance 3 37 Weekday patients 42 Male African Chest pain 2 Ambulance 4 91 Night American 60 Male White Chest pain 1 Walk-in 5 60 Weekday 81 Male White Chest pain 1 Ambulance 7 101 Weekend 41 Male White Chest pain 2 Walk-in 7 115 Night 67 Male White Chest pain 2 Walk-in 9 75 Weekday 66 Female White Chest pain 2 Walk-in 10 134 Night cath = catheterization; ECG = electrocardiogram; ESI = Emergency Severity Index; STEMI = ST-segment elevation myocardial infarction. DISCUSSION to meet the 10-minute door-to-ECG goal was to immediately identify eligible patients at the door. The Our data demonstrate that we were able to improve addition of trained personnel at the door was deemed adherence to the 10-minute goal of door-to-ECG time to be too costly. from 16% to 64%. We were able to accomplish this by Because of the relatively small number of STEMI acti- retraining our registration staff, eliminating the reassess- vations due to our patient population and demograph- ment by a triage nurse for chest pain, and prioritizing ics, we did not have the statistical power to perform a ECGs to an assigned ED technician. This initiative did thorough analysis of our STEMIs. We did capture all not utilize additional staff. patients who underwent a cath alert with the new pro- We were able to improve ECG time without regard cess. It appears that if a patient presents with chest to sex or race, which is important because there is pain during daytime hours, a short ECG time helps to abundant literature showing disparities in cardiac care improve DTB time, but due to the small number of for women and minorities.7,13–20 We were also able to patients, we were unable to show statistical signiﬁ- do it at a minimal cost (one new cell phone). cance. In contrast, during weekends and nights when Previously, two small studies that examined the initi- the cath team had to come to the hospital, DTB time ation of a multistrategy approach to reducing DTB time was relatively long. To meet a DTB time goal of showed reduced door-to-ECG times. In the ﬁrst, ECG <90 minutes, not only do we need to work on improv- time was reduced by performing routine ECGs in men ing ECG time, we need to improve the response time of >35 years or women >40 years old with nontraumatic the cath team. A study by Bradley et al.24 showed that chest pain.21 This strategy required an ED tech expecting cardiac cath team members to arrive within assigned to triage using a new dedicated ECG machine, 20 minutes of being paged saved a mean of 19.3 min- but the study does not detail how patients were identi- utes off of DTB time. ﬁed and whether a new tech was needed. The second Our initiative increased the total number of patients study of this type showed similar reduced door-to-ECG who received ECGs in triage between the pre- and time, but provides no details on how staff identiﬁed post-intervention period by almost 30%. During this patients with a ‘‘complaint consistent with angina.’’22 same time period, our census increased by 5%. This Another study showed that adding an ED triage increase in ECGs was undoubtedly due to the prompt- greeter improved ECG time.23 In this small study, an ing of chest pain in patients at registration. While it can extra triage staff member had the sole job of assessing be argued that this increase was for people who did the need for an ECG, then performing it if necessary; not need emergent ECGs, we believe these people this reduced overall ECG time. We believe that our ED would have received ECGs sometime during their ED environment reﬂects the actual clinical environment of visit. From the pre- to post-intervention period, the most busy EDs. We have limited resources and needed total number of ECGs performed in the ED decreased to address an important clinical issue without adding by 21%, suggesting that our initiative consolidated the personnel. performance of ECGs to earlier in the patient ED visit. The method we chose of identifying patients for Given that our patient population is heterogeneous with rapid ECGs by registration clerks was controversial. It respect to race and sex, and many of our younger was made with the knowledge that we would be patients with atypical symptoms may have coronary relying on untrained medical personnel. We suspected artery disease, we believe that it is better to obtain that this would probably increase the number of ECGs more ECGs earlier in the workup than to risk delaying recorded early in a patient visit. However, one way Copyright Agency Limited (CAL) licenced copy 926 Takakuwa et al. • ECG TIME a possible STEMI with a more atypical ACS presenta- 10-minute-or-less door-to-electrocardiogram time stan- tion. dard for chest pain patients presenting to a busy urban One arena that our initiative did not target was academic ED. This appeared to help achieve quicker patients who arrive by ambulance, who comprised 11% door-to-balloon time during hours when the catheteri- of our patients. We decided to keep ambulance patients zation team was on site, but not during nights and in the analysis even though they were not targeted for weekends. ECG time improvements. A post hoc analysis showed that eliminating ambulance arrivals had little effect on References the total results. We suspect that the signiﬁcant improvement for ambulance patients reﬂected a general 1. Anderson JL, Adams CD, Antman EM, et al. effort from our ECG technicians to improve ECG times. ACC ⁄ AHA 2007 guidelines for the management of It is possible to replicate the same procedure as for the patients with unstable angina ⁄ non-ST-elevation walk-in patients by having the ED clinical nurse page myocardial infarction: a report of the American Col- the ECG technician to the ambulance receiving area, lege of Cardiology ⁄ American Heart Association but this was not done. An alternative strategy would be Task Force on Practice Guidelines (Writing Com- to initiate prehospital wireless 12-lead ECG transmis- mittee to Revise the 2002 Guidelines for the Man- sion to the ED25 or a cardiologist’s hand-held device26 agement of Patients With Unstable Angina ⁄ Non ST- or to empower the paramedics to activate a cath alert Elevation Myocardial Infarction). Circulation. 2007; based on the ECG computer algorithm27,28 for all 116:e148–304. ambulance patients. Several studies have shown that 2. Antman EM, Anbe DT, Armstrong PW, et al. this strategy reduces door-to-reperfusion and DTB time ACC ⁄ AHA guidelines for the management of for STEMI patients.29,30 However, this was not prac- patients with ST-elevation myocardial infarction: a ticed in our city at the time of the study. report of the American College of Cardiol- ogy ⁄ American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 LIMITATIONS Guidelines for the Management of Patients with Our study is limited by its single location in an urban Acute Myocardial Infarction). Circulation. 2004; academic environment and the institutional idiosyncra- 110:e82–292. sies. The study was performed for a relatively short 3. Ofﬁce of Quality and Performance (10Q). FY 2008, duration and the improvements seen may gradually les- Q1 technical manual for the VHA performance mea- sen over time. We only included those patients who surement system. Washington, DC: Oct 31, 2007, p mentioned chest pain to the registration clerk. It is pos- 315. Available at: http://www.qualitymeasures. sible that patients who mentioned ACS equivalents ahrq.gov/summary/pdf.aspx?doc_id=9142&stat=1&- such as shortness of breath, weakness, and neck ⁄ shoul- string=. Accessed Jun 19, 2009. der ⁄ back pain and who did not have chest pain but had 4. Krumholz HM, Anderson JL, Bachelder BL, et al. ACS were missed for rapid ECGs. In our pre-interven- ACC ⁄ AHA 2008 performance measures for adults tion group, the two patients who had chief complaints with ST-elevation and non-ST-elevation myocardial of shortness of breath and dehydration respectively infarction: a report of the American College of Car- would not have been captured for rapid ECGs with the diology ⁄ American Heart Association Task Force on new intervention, because neither of them had chest Performance Measures (Writing Committee to pain. As the next step in our ECG process, we should develop performance measures for ST-elevation include all patients with ACS symptoms for rapid and non-ST-elevation myocardial infarction). Circu- ECGs. While this would have enabled us to obtain an lation. 2008; 118:2596–648. ECG on the patient with shortness of breath, we still 5. Diercks DB, Peacock WF, Hiestand BC, et al. Fre- would have missed the patient who complained of quency and consequences of recording an electro- dehydration. We recognize the importance of identify- cardiogram >10 minutes after arrival in an ing ACS equivalents, but decided to change the process emergency room in non-ST-segment elevation acute for obtaining ECGs in a stepwise fashion. It is also pos- coronary syndromes (from the CRUSADE Initia- sible that a patient may not have mentioned chest pain tive). Am J Cardiol. 2006; 97:437–42. to the registration clerk, but then went on to tell the tri- 6. Diercks DB, Kirk JD, Lindsell CJ, et al. 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