Improving the Timeliness and Quality of Electrocardiogram Acquisition, Interpretation, and Documentation in the Emergency Department: A Closed-Loop Quality Improvement Study at Hasahesa Teaching Hospital, Sudan.

Background Timely acquisition and accurate interpretation of electrocardiograms (ECGs) are essential for the early diagnosis and management of acute coronary syndromes (ACS) in emergency departments (EDs). Delays in ECG performance and deficiencies in documentation can compromise patient outcomes and quality of care, particularly in resource-limited settings. Objective This study aims to evaluate and improve the timeliness of ECG acquisition, interpretation, and documentation in the ED through a structured quality improvement approach. Methods A closed-loop quality improvement project was conducted at Hasahesa Teaching Hospital, Sudan, using a two-cycle clinical audit design structured around the Plan-Do-Study-Act (PDSA) framework. Data were collected prospectively over two audit cycles using a total population sampling approach. The first cycle was conducted over three months from June to August 2025 and included 90 patients. Following a two-month intervention phase, a second cycle was conducted over three months and included 105 patients, yielding a total of 195 cases. Key parameters assessed included time from arrival to ECG acquisition, time to interpretation and documentation, clinical indication, and completeness of ECG documentation. Targeted interventions included staff education, workflow optimization, and reinforcement of standardized documentation practices. Results The proportion of patients receiving ECG within 10 minutes of arrival increased significantly from 43/90 (47.8%) in the first cycle to 90/105 (85.7%) in the second cycle (p<0.001). The mean time from arrival to ECG acquisition decreased from 25.4 minutes to 4.5 minutes. Significant improvements were observed across all documentation parameters, including ST-segment documentation (25/90 (27.8%) to 91/105 (86.7%)), rhythm (50/90 (55.6%) to 85/105 (81.0%)), and rate (70/90 (77.8%) to 99/105 (94.3%)) (all p<0.01). Documentation of the PR interval, QRS complex, and axis also improved significantly. The proportion of patients diagnosed with ACS, including unstable angina, NSTEMI (non-ST-elevation myocardial infarction), and STEMI, decreased from 33/90 (36.7%) in the first cycle to 20/105 (19.0%) in the second cycle (p=0.007), while normal ECG findings increased, although not statistically significant. Conclusion Targeted quality improvement interventions resulted in significant enhancements in both the timeliness of ECG acquisition and the completeness of ECG documentation. These findings highlight the effectiveness of structured audit cycles and low-cost interventions in improving emergency cardiac care and emphasize the importance of sustained quality improvement efforts to ensure long-term impact.