Factors associated with delay in giving thrombolytic therapy after arrival at hospital

Objective: To identify factors associated with delay in administration of thrombolytic therapy for acute myocardial infarction. Design: Retrospective case note review of a six-month period in 1995. Data were obtained on age, sex, hospital arrival time, triage priority, assessment process in the emergency department, grade of emergency doctor, patient history, timing of and findings on electrocardiogram (EGG), type of infarct, timing and site of administration of thrombolytic therapy, and type of thrombolysis given. Setting: Tertiary referral hospital in Newcastle, New South Wales. Participants: Eighty-five patients given thrombolytic therapy for acute myocardial infarction. Outcome measure: Time between hospital arrival and initiation of thrombolytic therapy. Results: The median time from hospital arrival to administration of thrombolytic therapy was 80 minutes (interquartile range [IR], 50-133). Only 26% of patients were triaged to Priority 1 or 2 (to be seen by a doctor within 10 minutes). Patients initially assessed by a specialist emergency physician received thrombolytic therapy a median of 38 (IR, 33-50) minutes after hospital arrival, compared with 65 (IR, 50-107) minutes if initially assessed by a medical registrar, and 148 (IR, 89-185) and 160 (IR, 95-163) minutes, respectively, if initially assessed by an intern or a resident medical officer (P< 0.001). Factors associated with increased delay in receiving thrombolytic therapy (after adjustment for possible confounders) were low triage priority, initial assessment by a junior doctor, atypical presenting history of myocardial infarction, and lesser degrees of ST-segment elevation on the presenting ECG (all P less than or equal to 0.01). Conclusions: Delay in administration of thrombolytic therapy in hospital results from a combination of hospital and patient factors. Changes in emergency department protocol may reduce these delays in some patients.