# Optimizing Electrocardiogram Procedures in the Emergency Management of Suspected Acute Coronary Syndrome: A Clinical Audit at Al Damar Teaching Hospital, Sudan

## TL;DR

This study shows that simple interventions can greatly improve ECG procedures in emergency departments with limited resources, leading to faster diagnosis of heart attacks.

## Contribution

The study demonstrates that low-cost, targeted interventions can significantly improve ECG processing in resource-limited emergency departments.

## Key findings

- ECG acquisition within 10 minutes increased from 23.8% to 100% after interventions.
- Average time from patient arrival to ECG acquisition decreased by 88.7%.
- Documentation quality improved significantly for rhythm, rate, and ST-segment analysis.

## Abstract

Introduction: Acute coronary syndrome (ACS) is a time-sensitive condition requiring prompt diagnosis and management. The 12-lead ECG is central to early identification and is to be conducted soon after emergency department (ED) presentation. However, adherence in resource-limited settings remains suboptimal. This audit aimed to evaluate and improve ECG acquisition, interpretation, and documentation at Al Damar Teaching Hospital in Sudan.

Methods: A two-cycle clinical audit was conducted using American Heart Association (AHA) and American College of Cardiology (ACC) benchmarks. The first cycle (May to June 2024) identified baseline performance in ECG timeliness and quality. Interventions included staff education, visual reminders, and workflow optimization. The second cycle (October to November 2024) assessed the impact of these interventions. Data were collected via a structured checklist, and analysis was performed using SPSS Statistics version 25 (IBM Corp., Armonk, NY, USA) with significance set at p<0.05.

Results: A total of 46 patients were included (21 in the first cycle, 25 in the second). The proportion of patients receiving ECGs within 10 minutes increased from five (23.8%) to 25 (100%) (p<0.001), and the average time from arrival to ECG acquisition dropped by 88.7%. Interpretation time also improved significantly (69.8%, p=0.0001). Documentation quality improved for rhythm (10 (47.6%) to 21 (84%), p=0.003), rate (12 (57.1%) to 20 (80%), p=0.009), and ST-segment (16 (76.2%) to 24 (96%), p<0.00001), although documentation of PR interval, QRS complex, and axis declined. The proportion of patients diagnosed with ACS rose from 18 (85.7%) to 25 (100%).

Conclusion: Targeted, low-cost interventions significantly enhanced ECG processing efficiency and documentation quality in a resource-limited emergency department. These findings underscore the potential for structured audits to drive sustainable quality improvement in ACS care pathways across similar settings.