The use of audit to set up a thrombolysis programme in the accident and emergency department.

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Abstract
OBJECTIVE: To improve the thrombolysis service offered by Gloucester Royal Hospital, by reducing the "door to needle time" (DTN) to 30 min (from a median of 110 min), and increasing the proportion of patients with acute myocardial infarctions receiving thrombolysis to 70% (from 58%). This would be achieved by moving the thrombolysis programme from the coronary care unit (CCU) to the accident and emergency (A&E) department. DESIGN: The process of audit was used to identify an area of poor performance, set standards, acquire funding, demonstrate achievement, and subsequently secure recurrent funding. SETTING: Gloucester Royal Hospital. SUBJECTS: 946 patients presenting consecutively to the A&E department with non-traumatic chest pain between August 1993 and March 1994. MAIN OUTCOME MEASURES: DTN, overall delay time, and acute myocardial infarction thrombolysis rate. RESULTS: 946 patients were assessed over the eight month period, of whom 266 (28%) had suffered an acute myocardial infarction; 182 (68%) received thrombolysis (compared to 58% previously P < 0.05). Median DTN was reduced to 38 min (v 110 min previously, P < 0.0006). 127 (70%) patients received thrombolysis in the A&E department, and 55 (30%) in the CCU. Median overall delay time between onset of pain and thrombolysis was 3 h 35 min; 70% of patients received thrombolysis within 6 h of onset of symptoms and 90% within 12 h. Re-audit has subsequently shown maintenance of improvement. CONCLUSIONS: An in-house A&E based thrombolysis programme works in the District General Hospital setting; the process of audit can be used to acquire, and subsequently secure, funding for the project. The key to successful implementation of change is sensible resource allocation into adequate staffing and appropriate education.