Improving the non-ST-segment elevation acute coronary syndrome (NSTEACS) pathway using quality improvement methodology.

Abstract

Background: The National Institute for Health and Care Excellence (NICE) guideline quality standard for non-ST-segment elevation acute coronary syndrome (NSTEACS) pathway states that adults who have an intermediate or higher risk of future adverse cardiovascular events should undergo coronary angiography within 72 hours of first admission to hospital.The aim was to improve compliance with the 72-hour NICE quality standard for the acute coronary syndrome pathway between one district general hospital (DGH) and its cardiac tertiary centre by reducing the time from admission to angiography by 50%.Participants were front-line staff in the DGH and staff in the cardiac catheter laboratory in the tertiary centre.

Methods: Continuous data were collected prospectively on all patients entering the NSTEACS pathway with time of arrival to hospital; referral to angiography; and start of angiogram to measure the NSTEACS pathway duration against the NICE quality standard. We used process mapping, ease-benefit matrix, Pareto analyses and the Institute for Healthcare Improvement (IHI) Plan-Do-Study-Act (PDSA) method of quality improvement.

Intervention: Staff in both hospitals performed process mapping of their respective parts of the NSTEACS pathway. Their data informed decisions on process changes using the ease-benefit matrix. PDSA cycles were commenced, and changes were assessed using continuous measurement of pathway duration. In the tertiary centre, Pareto analysis was performed to help identify the major service constraints.

Results: Between January 2021 and March 2023, there were four separate PDSA cycles, two each in the DGH and tertiary centre. Across the four PDSA cycles, the time to complete the pathway reduced from an average of 172 to 94.72 hours, an improvement of 45%, along with an overall reduction in variability of data. In the DGH, the process changes were sustained, but in the tertiary centre they were not, as PDSA 4 required staff recruitment to enable a 6-day rather than a 5-day service per week.